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RECAP 


PRINCIPLES  OF 
MEDICAL  TREATMENT 


GEORGE  CHEEVER  SHATTUCK,M.D. 


Columbia  (Hnittfttfitp 
mtl)eCilprf3Srtu|0rk  )<3f& 

College  of  i^jjpaictans;  anb  burgeons 


TLibvavp 


Rt<° 


PRINCIPLES  OF 
MEDICAL  TREATMENT 


BY 
GEORGE  CHEEVER  SHATTUCK,  M.D. 

Assistant  Physician  to  the  Massachusetts 
General  Hospital 


THIRD  EDITION 
REVISED  AND  ENLARGED 


^ 


BOSTON : 
W.  M.  LEONARD,  Publisher 
1916     " 


COPYRIGHT 
BY 

W.  M.  LEONARD 

1916 


sva 

Y5>\G> 


TO 

WILLIAM  HENRY  SMITH,  M.D. 

TEACHER  IN  MEDICINE 

AND 

ERIEND  TO  MANY 


CONTENTS   AND    INDEX. 


PAGE 

Preface 12 

CHAPTER  I. 
CARDIAC    INSUFFICIENCY. 

Principles  of  Treatment 13 

Methods  of  Treatment:  — 

(a)  Rest 13 

(6)  Depletion 13 

(c)  Stimulation 17 

(d)  Diet 19 

(e)  Regulation  of  Mode  of  Life 19 

Valvular  Disease :  — 

Classification  of  Valvular  Disease 19 

Pathology  and  Diagnosis 21 

Treatment  for:  — 

I.     Congenital  and  Obsolete  Infectious  Valve 

Lesions 23 

II.     Active  Infectious  Lesions 23 

III.  Syphilitic  Valve  Lesions 25 

IV.  Degenerative  Valve  Lesions 25 

Hypertension  with  Cardiac  Insufficiency 27 

Acute  Pulmonary  Edema  with  Hypertension 27 

Pulmonary  Edema  without  Hypertension 29 

Circulatory  Disorders  in  the  Infectious  Diseases:  — 

Cardiac  Disorders 31 

Vascular  Relaxation,  "Vasomotor  Paresis" 33 

Angina  Pectoris:  — 

Classification 37 

Diagnosis 37 

4 


5 

PAGE 

Syphilitic  Angina:  — 

Treatment  in  General 39 

Treatment  of  Attack 39 

Degenerative  Angina:  Treatment 41 

Embolic  Angina:  Treatment 41 

Neurotic  Angina:  Treatment 41 

CHAPTER  II. 

NEPHRITIS. 

Classification 43 

Differentiation  of  Types 45 

Acute  Renal  Irritation:  Treatment 47 

Acute  Nephritis :  — 

Principles  of  Treatment 49 

Methods  of  Treatment:  — 

Sweating 49 

Purgation 51 

Diet 51 

Liquids 53 

Nutrition 53 

Medication 53 

Prophylaxis 53 

Chronic  Nephritis :  — 

Principles  of  Treatment 55 

Methods  of  Treatment 55 

Syphilitic  Nephritis 57 

Arteriosclerotic  Degeneration:  Treatment 57 

Passive  Congestion:  Treatment 57 

Uremia:  — 

Methods  of  Treatment 59 

CHAPTER  III. 

ACUTE    INFECTIOUS    DISEASES. 

Principles  of  Treatment 63 

Typhoid  Fever. 

Principles  of  Treatment 65 

Routine  Orders 65 


6 

PAGE 

Methods  of  Treatment:  — 

Prophylaxis 67 

Dilution  and  Elimination  of  Toxins 67 

Conservation  of  Strength 69 

Diet 69 

Medication 71 

Observation 71 

Convalescence 73 

Nursing 73 

Symptomatic  Treatment:  — 

Fever  and  Toxemia 75 

Circulatory  Weakness 77 

Diarrhcea 79 

Constipation 79 

Distention 79 

Vomiting 79 

Headache 81 

Complications,  Treatment  of:  — 

Hemorrhage 81 

Perforation 81 

Rheumatic  Fever. 

Principles  of  Treatment 83 

Methods  of  Treatment 83 

ACUTE  INFECTIONS  MOST  COMMON  IN  CHILDHOOD. 

By  Edwin  H.  Place,  M.D. 

Scarlet  Fever. 

Prophylaxis  :  — 

Immunity 87 

Asepsis 87 

Isolation 87 

Quarantine 89 

Disinfection 89 

Treatment: 

Toxemia 91 

General  Sepsis 91 

Local  Sepsis 93 


7 

PAGE 

Nephritis 97 

Cardiac  Complications 99 

Fever 99 

Measles. 

Prophylaxis 101 

Treatment  — 

Acute  Toxemia 101 

Mucous  Membrane  Infections 103 

Pertussis. 

Prophylaxis 105 

Treatment 105 

Varicella. 

Prophylaxis 109 

Treatment 109 

Diphtheria. 

Prophylaxis  :  — 

Immunity Ill 

Asepsis Ill 

Isolation Ill 

Quarantine 113 

Treatment:  — 

Toxemia 113 

Obstruction  to  Breathing 113 

Local  Treatment 113 

Complications  :  — 

Cardiac 115 

Paralysis 115 

Chronic  Obstruction  of  Larynx 117 

Serum  Disease 117 

Carriers 119 

PULMONARY  INFECTIONS.  | 

Lobar  Pneumonia. 

Principles  of  Treatment 121 

Methods  of  Treatment 121 

Stimulation  of  Heart 123 

Delirium:  Treatment 125 


8 

PAGE 

Broncho-pneumonia 125 

Bronchitis,  Acute :   Treatment 127 

Bronchitis,  Chronic:   Treatment 129 

Bronchiectasis:  Treatment 129-131 

PULMONARY    TUBERCULOSIS. 

By  John  B.  Hawes  2nd,  M.D. 

Course  of  the  Disease 133 

Complications  and  Sequeli^e 133 

Diagnosis 133 

Prophylaxis 135 

Treatment  in  General 135 

Sanatorium  Treatment 137 

Home  Treatment 137 

Climate 137 

Tuberculin 139 

Heliotherapy 139 

Drugs 139 

ACUTE  INFLAMMATION  OF  THE  UPPER 
RESPIRATORY  TRACT. 

Etiology 141 

Complications  and  Sequell^e 141 

Diagnosis 141 

Prophylaxis ......  141 

Treatment  Applicable  in  General 143 

Acute  Pharyngitis  :  Treatment 145 

Coryza  :  Treatment 145 

Acute  Tonsillitis  :  Treatment 145 

Acute  Laryngitis:  Treatment 147 

Acute  Tracheitis:  Treatment 147 

CHAPTER   IV. 
GASTRIC    AND    DUODENAL    ULCER. 

Indications  for  Medical  Treatment 149 

Principles  of  Treatment 149 

Methods  of  Treatment 149 

Diet 149,  157 


9 

PAGE 

Complications,  Treatment  of:  — 

Hemorrhage 153 

Perforation 1 55 

Pyloric  Obstruction 155 

Persistent  Severe  Symptoms 155 

Acute  Indigestion. 

Diagnosis 159 

Principles  of  Treatment 159 

Methods 159 

Simple  Diarrhoea. 

Diagnosis 163 

Principles  of  Treatment 163 

Methods  of  Treatment 165 

Medication 165 

Constipation. 

Classification 167 

Principles  of  Treatment 167 

Methods:  — 

Spasmodic  Constipation 169 

Atonic  Constipation 171 

Obstructive  Constipation 171 

Various 171 

CHAPTER  V. 

Foreword 175 

Abbreviations 177 

SYNOPSIS    OF   DRUGS. 

Important  Drugs: 

1.  Salvarsan  and  Neosalvarsan 179-185 

2.  Mercury 185 

3.  Iodide  of  Potash 189 

4.  Diphtheria  Antitoxin 191 

5.  Morphine 191 

6.  Digitalis 195 


10 

PAGE 

7.  Nitroglycerin  and  Nitrites 197 

8.  Theobromine 199 

9.  Magnesium  Sulphate  and  Other  Purgatives...  201 

10.  Quinine 203 

11.  Salicylate 203 

12.  Hexamethylenamine 205 

Valuable  Drugs  and  Non-medicinal  Preparations: 

13.  Blaud's  Pill 209 

14.  Trional 209 

15.  Bromide 209 

16.  Phenacetin 209 

17.  Dover's  Powder 211 

18.  Codeine 211 

19.  Sodium  Bicarbonate 211 

20.  Bismuth 211 

21.  Calomel 211 

22.  Castor  Oil 213 

23.  Cascara 213 

24.  Vaccine  Virus 213 

25.  Typhoid  Vaccine 215 

26.  Tuberculin 215 

27.  Normal  Salt  Solution 215 

28.  Alcoholic  Beverages 215 

29.  "Russian  Oil" 217 

30.  Agar-Agar 217 

Drugs  Valuable  for  Occasional  Use: 

List  of: 221 

Drugs  in  Common  Use: 

List  of: 223 

Tables  of  Weights  and  Measures 225 


PREFACE. 


This  work  represents  an  attempt  to  offer  clearly  and  concisely 
sound  principles  of  treatment  based  on  known  pathology.  The 
methods  described  are  selected  from  those  that  have  been  tried 
at  the  Massachusetts  General  Hospital  or  in  private  practice. 
Most  of  them  have  been  taught  by  Prof.  F.  C.  Shattuck,  Dr. 
William  H.  Smith  or  others  on  the  staff  of  the  Hospital  or  of  the 
Harvard  Medical  School.  It  is  not  to  be  supposed  that  any  of 
these  men  subscribe  fully  to  everything  here  set  forth  or  that 
further  advance  will  not  require  revision. 

The  writer  wishes  here  to  express  his  deep  appreciation  of  the 
debt  which  he  owes  to  his  teachers  in  medicine,  of  their  kindliness 
to  pupils  and  of  their  humanity  to  patients. 

Brevity  being  essential  to  the  writer's  purpose,  this  synopsis 
is  necessarily  incomplete.  The  book  was  prepared  primarily 
for  use  in  the  Harvard  Medical  School. 


PREFACE  TO   SECOND   EDITION. 


In  this  edition,  as  in  the  first,  completeness  has  been  sacrificed 
to  brevity,  but  new  material  has  been  added  and  many  changes 
have  been  made. 

More  reliance  than  before  has  been  placed  on  personal  ex- 
perience, but  the  information  about  salvarsan  was  derived, 
chiefly,  from  recent  literature. 

It  is  a  pleasure  to  acknowledge  the  assistance  and  helpful 
criticism  of  friends  and,  notably,  that  of  Mr.  Godsoe,  Phar- 
macist of  the  Massachusetts  General  HospitaL 

G.  C.  S. 


PREFACE  TO   THIRD   EDITION. 


This  book  has  grown  considerably  since  the  first  edition  ap- 
peared, and  the  original  name,  "  A  Synopsis  of  Medical  Treat- 
ment "  has  been  criticized  on  the  ground  that  it  gave  an 
inadequate  idea  of  the  scope  of  the  book.  I  was  the  more 
ready  to  change  the  title  because,  from  the  first,  it  has  been 
my  desire  to  subordinate  methods  and  to  emphasize  principles. 
Accordingly  the  name  of  the  book  has  been  changed  to  ' '  Prin- 
ciples of  Medical  Treatment." 

I  count  it  a  piece  of  rare  good  fortune  to  be  able  in  this  edi- 
tion to  publish  new  material  on  some  of  the  acute  infections  by 
Dr.  Edwin  H.  Place  and  on  tuberculosis  by  Dr.  John  B.  Hawes 
2nd,  men  whose  work  in  their  respective  fields  is  so  favorably 
known  as  to  render  comment  unnecessary.  G.   C.   S. 


CHAPTER  I. 


CARDIAC    INSUFFICIENCY. 
GENERAL   PRINCIPLES   OF   TREATMENT. 

A.  Rest. 

B.  Depletion. 

C.  Stimulation. 

D.  Suitable  Diet. 

E.  Regulation  of  Mode  of  Life. 

The  principles  are  much  the  same  whatever  the  underlying 
cause.  Treatment  must,  however,  be  regulated  to  suit  the 
severity  of  symptoms,  to  meet  individual  needs,  and  for  varie- 
ties of  disease. 

An  exact  diagnosis  may  be  difficult  in  the  presence  of  severe 
insufficiency  and  may  not  be  necessary  at  first,  but  accuracy  in 
diagnosis  is  very  important  for  prognosis  and  for  planning 
treatment  for  the  future. 

METHODS    OF   TREATMENT. 
A.     Rest. 

1.  Semirecumbent  position  in  bed  or  chair. 

2.  Minimum  exertion. 

3.  Relieve  discomfort   and  secure  sleep.     If  there  is  much 

discomfort  morphine  subcutaneously  is  indicated. 

B.     Depletion. 

1.  Purgation.     Obtain  watery  catharsis  more  or  less  profuse 

according  to  amount  of  edema. 
When  edema  is  absent  or  slight  avoid  excessive   purgation   lest 
exhaustion  result. 

Magnesium  sulphate  (p.  201)  is  useful  as  a  purgative. 

13 


15 


2.  Limitation  of  Liquids.  Total  liquids,  including  liquid  foods, 
should  not  exceed  three  pints  in  twenty-four  hours.  One  pint 
in  twenty-four  hours  is  near  the  minimum.  The  patient  should 
not  be  allowed  to  suffer  from  thirst.  It  may  be  relieved  by 
sucking  cracked  ice  or  by  gargling. 

3.  Diuresis  should  follow  the  use  of  digitalis.  In  mild  cases 
of  insufficiency,  rest,  purgation  and  limitation  of  liquids  with 
or  without  digitalis  may  suffice. 

When  edema  is  persistent  or  extreme,  diuretics  should  be 
prescribed.  Theobromine  (p.  199)  or  its  substitutes  may  be  ex- 
pected to  act  well  provided  the  kidneys  are  not  severely  damaged. 
Calomel  should  not  be  given  if  the  patient  has  nephritis  because 
salivation  may  result.  Apocynum,  theocine  or  theophylline 
may  act  better  than  theobromine  in  some  cases. 

4.  Venesection.  Indicated  occasionally  when  there  is  en- 
gorgement of  the  right  ventricle  with  marked  evidence  of  venous 
stasis;  e.g.,  dyspnoea,  cyanosis,  pulmonary  edema  and  engorge- 
ment of  neck-veins  and  liver. 

A  pint  of  blood  or  even  more  may  be  withdrawn.  Venesection 
is  contraindicated  by  emaciation  or  by  marked  weakness  or 
anemia.  Blood  is  generally  withdrawn  by  incising  a  vein  on 
the  inner  side  of  the  elbow.  A  tourniquet  may  be  put  around 
the  arm  to  render  the  veins  prominent.  The  incision  should 
be  made  in  the  long  axis  of  the  vein  with  the  point  of  a  sharp 
knife.  The  bleeding  can  be  stopped  with  a  pad  and  bandage. 
Suturing  the  vein  is  unnecessary. 

5.  Leeching.  Useful  as  a  substitute  for  venesection  when 
the  latter  would  be  undesirable  or  when  symptoms  are  less 
severe.  Leeching  will  generally  relieve  painful  engorgement 
of  the  liver. 

Apply  a  dozen  leeches  over  the  right  hypochondrium  and 
allow  them  to  remain  until  they  drop  off.  The  abdomen  should 
then  be  covered  with  a  large,  moist,  absorbent  dressing  to  favor 
oozing  from  the  bites.  A  drop  of  milk  placed  on  the  skin  en- 
courages the  leech  to  bite.     Salt  causes  him  to  let  go. 

6.  Tapping.  Necessary  when  fluid  in  the  chest  or  abdominal 
cavity  seriously  embarrasses  the  heart  or  respiration. 


17 


C.     Stimulation. 

Digitalis  (p.  195)  is  the  best  cardiac  stimulant  (other  drugs 
may  be  preferred  occasionally).  A  good  tincture  *  of  digitalis 
ordinarily  acts  well.  If  after  pushing  digitalis  no  effects  are 
apparent  the  preparation  is  probably  bad.  When  given  by 
mouth  in  sufficient  dosage  its  action  should  be  apparent  in  from 
twenty-four  to  forty-eight  hours.  When  quicker  results  are 
needed  an  initial  dose  of  30  min.  (or  2  c.c.)  may  be  injected  into 
the  gluteal  muscle. 

When  prompt  effects  are  desirable  digipuratum  (p.  197)  can 
be  used.  When  given  by  mouth  it  should  act  in  from  twelve 
to  twenty-four  hours.  Digipuratum-solution  injected  intramus- 
cularly may  show  effects  in  from  \  to  1  hour.  It  acts  more 
quickly  when  used  intravenously.  For  very  urgent  insufficiency 
strophanthin  may  be  used  intravenously.  It  is  dangerous 
(p.  197). 

Caffeine  sodio-salicylate  is  believed  to  promote  diuresis  when 
used  in  conjunction  with  digitalis.  For  this  purpose  the  caffeine 
should  be  used  subcut.  in  repeated  doses  of  from  1  to  3  grs. 
(or  0.06  to  0.2  gm.). 

Black  coffee  or  caffeine  citrate  may  be  tried  by  mouth.  Caf- 
feine may  cause  restlessness  or  insomnia. 

Slight  exacerbations  of  dyspnoea  or  distress  can  often  be  re- 
lieved by  a  quickly  diffusible  stimulant,  e.g.: 

By  mouth: 

(a)  Spiritus  ammoniae  aromaticus:     1  drach.  (or  4  c.c). 
(6)  Whiskey  or  brandy:   from  \  to  1  oz.  (or  15  to  30  c.c). 

Subcutaneously : 

(c)  Camphor  in  oil:  f  3  grs.  (or  0.2  gm.).     Inject  intramus- 

cularly. 

(d)  Cocaine  hydrochloride:    from  |  to  J  gr.     (or  0.008 

to  0.016  gm.).     It  is  said  to  be  dangerous  but  may 
act  very  well. 


*  Many  prefer  powdered  leaves  in  pill-form. 
t  Should  be  specially  prepared  for  subcut.  use. 


19 


Insufficiency  with  much  pain  requires  morphine  (p.  191).  It 
seems  to  act  under  these  circumstances  as  an  efficient  cardiac 
stimulant.  It  brings  also  physical  comfort  and  psychic  relief 
which  favor  recuperation.  The  morphine  should  be  used  subcut. 
under  these  circumstances  to  ensure  prompt  effect. 

D.    Diet. 

Spare  the  patient  unnecessary  effort,  particularly  if  there  is 
much  dyspnoea,  by  ordering  food  which  is  easy  to  swallow  and 
which  requires  no  chewing. 

By  frequent  small  feedings  and  by  avoiding  gas-producing 
foods  seek  to  prevent  cardiac  embarrassment  from  distention. 

Emaciated  patients  should  take  as  much  concentrated  nourish- 
ment as  is  practicable  in  order  to  strengthen  the  heart  muscle 
by  improved  nutrition. 

Fat  or  plethoric  individuals  may  benefit  by  fasting. 

E.    Regulation  of  Mode  of  Life. 

To  prevent  relapse  during  and  after  convalescence,  the  mode 
of  life  of  the  patient  must  be  wisely  regulated;  and  intelligent 
cooperation  between  patient  and  physician'  is  essential  to  this 
end.  It  is  generally  necessary  to  tell  the  patient  something 
about  his  condition  and  to  warn  him  to  avoid  activities  which 
induce  much  fatigue  and  exertions  which  cause  much  dyspnoea. 

Judgment  and  caution  must  be  exercised  in  dealing  with  an 
apprehensive  patient  lest  danger  be  exaggerated  in  his  mind,  and 
harm  result.  After  a  sufficient  period  of  complete  rest  the  patient 
should  be  encouraged  to  take  regular  exercise  within  the  limits 
of  tolerance  in  order  to  strengthen  the  heart  by  promoting 
hypertrophy. 

Exercise  and  work  should  be  resumed  very  gradually  under 
close  supervision. 

CLASSIFICATION  OF  VALVULAR  DISEASE. 

..    ^,  .,  ,  (Most    commonly    discovered    in    early 

1.  Congenital    .     .  {     chiMhood 

2.  Infectious      .      .     Most  commonly  discovered  in  youth. 

o    q     ,  '.,.,,  (Most  commonly  discovered  in  middle 

'   i     life. 
4.  Degenerative      .     Most  commonly  discovered  in  old  age. 


21 


NOTES   ON   PATHOLOGY   AND   DIAGNOSIS. 

1.  Congenital  lesions.  Pulmonic  stenosis  is  the  most  common. 
It  is  seldom  mistaken  for  other  types  of  lesion  but  may  easily 
be  confused  with  anomalies  which  have  similar  signs  and  which 
are  often  combined  with  it. 

2.  Infectious  lesions: 

(a)  Active  stage.     Inflammation  of  valves  due  to  presence 
of  bacteria  on  the  valve. 

(b)  Obsolete    stage.     Valves   deformed    and   scarred   as   a 
result  of  inflammation. 

(c)  Recurrent  stage.     Reinfection  with  inflammation  at  site 
of  old  lesion. 

Lesions  are  found  commonly  at  the  mitral  valve  or  at  the  aortic 
and  mitral  valves,  seldom  at  the  aortic  valve  alone.  Occasion- 
ally the  mitral,  aortic  and  tricuspid  valves  are  all  diseased. 
Stenosis  develops  frequently. 

Obsolete  lesions  if  well  compensated  may  give  no  symptoms. 
They  first  attract  attention  by  diminished  cardiac  efficiency 
or  by  failure  of  compensation. 

In  the  active  or  recurrent  stage  the  symptoms  are  those  of 
general  infection  with  or  without  failure  of  compensation. 

3.  Syphilitic  lesions.  The  lesion  generally  begins  in  the  as- 
cending aorta  and  extends  subsequently  to  the  aortic  valve. 
The  earliest  signs  may  be  slight  dilatation  of  the  arch  and  the 
murmur  of  aortic  roughening.  Later,  that  of  aortic  regurgi- 
tation may  appear  and,  finally,  relative  mitral  regurgitation  may 
develop. 

A  lesion  of  the  aortic  valve  only,  in  a  young  adult,  suggests 
syphilis  as  its  cause.  Aneurism  or  coronary  endarteritis  may 
coexist  as  part  of  the  same  process. 

Evidence  of  an  old  syphilis  supports  the  diagnosis. 

4.  Degenerative  lesions.  As  in  syphilis,  the  signs  point  to 
a  lesion  at  the  aortic  valve  but  evidence  of  syphilis  is  lacking. 
The  background  is  one  of  senility  and  general  arteriosclerosis  to 
which  sclerosis  of  the  aorta  and  of  the  aortic  valve  is  incidental. 
There  may  be  dilatation  of  the  arch  and  evidence  of  myocardial 
degeneration,  perhaps  also  angina  pectoris. 

Note.  —  All  the  types  of  lesion  enumerated  above  may  be 
followed  in  time  by  cardiac  insufficiency. 


23 


TREATMENT   FOR   TYPES   OF  VALVULAR  DISEASE. 

I.  Congenital  and  Obsolete  Infectious  Lesions  of  Valves. 

Treat  according  to  the  general  principles  given  above. 
They  must  be  modified  for  the  individual  with  regard  to 
severity,  duration,  nature  and  cause  of  symptoms. 

II.  Active- Infectious  Lesions  of  Valves. 

A.  Principles  of  Treatment.  As  for  acute  infections  in  general 
(p.  23)  and  for  cardiac  insufficiency  if  present. 

1.  Rest  in  bed. 

2.  Minimum  exertion. 

3.  Dilution  of  toxins. 

4.  Elimination  of  toxins. 

5.  Maintenance  of  nutrition. 

6.  Stimulation  p.r.n. 

Note.  —  The  infection  may  be  acute,  subacute  or  recurrent. 
The  chief  dangers  are  from  toxemia,  exhaustion,  cardiac  dila- 
tation or  embolism. 

A  history  of  recent  preexisting  rheumatic  fever,  chorea  or 
tonsillitis  strengthens  a  diagnosis  of  active  endocarditis. 

B.  Methods,  (a)  Good  nursing  is  very  important.  The 
nurse  should  promote  comfort  by  attention  to  details,  should  feed 
the  patient  and,  whenever  possible,  spare  him  exertion  or  annoy- 
ance. 

(6)  To  dilute  toxins  and  to  favor  elimination  order  abundance 
of  liquids.  Have  intake  and  output  recorded.  If  cardiac  dila- 
tation threatens  or  if  there  is  edema  liquids  must  be  restricted. 

(c)  Feedings  should  be  frequent,  the  food  nutritious,  and  the 
amount  regulated  by  digestive  power.  Liquids  and  soft  solids 
are  preferable  in  severe  cases  because  easy  to  swallow. 

(d)  Stimulants  are  to  be  avoided  unless  clearly  necessary  be- 
cause embolism  is  to  be  feared  and  stimulation  might  favor 
it. 

(e)  Tachycardia  may  sometimes  be  reduced  by  an  ice-bag 
placed  over  the  prsecordia. 

C.  Convalescence.  To  minimize  danger  of  relapse  keep  the 
patient  in  bed  and  as  quiet  as  possible  for  weeks  or  months  after 


25 


the  pulse  and  temperature  have  returned  to  normal.  Permanent 
damage  nearly  always  remains.  The  degree  of  possible  im- 
provement depends  on  the  location  and  extent  of  the  lesions  and 
on  the  recuperative  power  of  the  patient.  Therefore,  guard 
against  strain,  and  treat  malnutrition  or  anemia,  if  present,  to 
promote  hypertrophy  of  the  heart. 

D.  Prophylaxis,  (a)  Search  for  and  eliminate  all  foci  of 
infection  in  sinuses,  teeth,  tonsils,  or  genito-urinary  tract. 

(6)  Diseased  tonsils,  as  a  rule,  should  be  removed  at  the  first 
suitable  opportunity.  It  is  dangerous  to  remove  them  when 
acutely  inflamed. 

(c)  Warn  the  patient  against  exposure  and  insist  that  he 
attend  promptly  to  ailments,  even  if  slight,  and  avoid  mental 
strain,  and  any  physical  exertion  which  produces  dyspnoea  or 
fatigue. 

III.  Syphilitic  Lesions  of  Valves  require  antisyphilitic  medi- 
cation as  well  as  general  measures  for  cardiac  insufficiency. 

Little  improvement  can  be  expected,  however,  unless  the 
diagnosis  be  made  before  extensive  and  irreparable  damage  has 
occurred. 

IV.  Degenerative  Lesions  of  Valves  may  be  treated  on  gen- 
eral principles  with  certain  modifications  as  follows: 

(a)  When  blood-pressure  is  high,  nitrites  may  be  of  value  to 
lighten  the  work  of  the  heart  by  lowering  pressure  temporarily. 

(b)  Thin  patients  require  the  maximum  nutrition  to  strengthen 
the  heart.  They  should  undergo  little  or  no  purgation  unless 
edema  is  considerable. 

(c)  Regulation  of  life  is  of  the  utmost  importance  during  and 
after  convalescence.     The  patients'  cooperation  must  be  secured. 

(d)  Many  of  these  patients  should  take  digitalis  and  salts 
more  or  less  frequently  for  long  periods  or  for  the  rest  of  their 
lives.  The  best  dosage  for  the  individual  can  be  determined 
only  by  trial.  Several  small  doses  per  week  taken  at  regular  in- 
tervals may  be  sufficient.  Warn  the  patient  not  to  be  without  his 
medicine  or  to  give  it  up  on  his  own  responsibility.  The  heart 
muscle  may,  perhaps,  be  so  changed  that  it  cannot  respond  to 
any  form  of  treatment. 


27 


HYPERTENSION   WITH   CARDIAC  INSUFFICIENCY. 

Etiology  and  Symptoms.  Hypertension  is  commonest  in 
chronic  nephritis  and  is  seen  also  in  arteriosclerosis.  The  hyper- 
tension and  left  ventricular  hypertrophy  develop  gradually. 
Symptoms  of  insufficiency  often  increase  so  gradually  as  to  be 
disregarded  by  the  patient  for  months.  The  condition  of  the 
patient  is  generally  more  critical  than  the  signs  would  seem  to 
indicate.  Acute  pulmonary  edema  is  common  in  these  cases. 
Many  of  them  show  signs  of  toxemia  attributable  to  deficient 
renal  elimination. 

Treatment.     1.  Methods  for  cardiac  insufficiency  (p.  13). 

2.  Reduce  the  work  of  the  heart  by  lowering  blood-pressure 

temporarily  unless  the  urinary   output  falls  in   con- 
sequence, 
(a)  Vaso-dilators,  e.g.,  nitroglycerin  (p.  197),  lower  blood- 
pressure  temporarily  and  often  promote  diuresis  also. 
(6)  Purgation,  diuresis,  venesection  and  measures  tending 
to  relieve  toxemia  or  to  improve  the  circulation  seem 
to  favor  if  not  to  cause  reduction  of  pressure  in  hyper- 
tension. 

(c)  Fasting   for  a  day  or  marked  restriction  of  food  for 

several  days  may  benefit  plethoric  individuals.  It 
is  one  of  the  surest  means  of  lowering  pressure.  Ema- 
ciation must  be  avoided  because  it  increases  cardiac 
weakness. 

(d)  Relief  from  psychic  strain,  e.g.,  business  cares,  may  be 

followed  by  a  fall  in  pressure. 

3.  When  toxemia  is  present  reduce  it  by: 

(a)  Purgation  or  diuresis. 

(b)  Restriction  of  food,  and  of  proteid  in  particular. 

(c)  Hot-air  baths  or  hot  soaks  if  cardiac  symptoms  permit. 

4.  If  toxemic  symptoms  persist  after  improvement  in  the 

circulation  they  are  probably  uremic  in  origin  and 
should  be  treated  accordingly  (p.  59). 

ACUTE   PULMONARY  EDEMA  IN  HYPERTENSION. 

Notes.  —  Occurs  commonly  and  characteristically  in  hyper- 
tension. The  attack  generally  follows  exertion  and  may  not 
have  been  preceded  by  marked  symptoms  of  cardiac  insufficiency. 

The  onset  is  sudden  and  alarming. 


29 


The  symptoms  are  severe  dyspncEa,  cyanosis,  wheezing,  cough, 
and  pinkish,  frothy  expectoration.  There  may  be  precordial 
pain. 

Treatment.  Mild  attacks  may  pass  off  after  a  little  rest. 
Severe  attacks  require  energetic  and  prompt  treatment  as 
follows: 

1.  Prop  the  patient  up  so  he  can  sit  upright  without  effort. 

2.  Give  morphine  sulphate,  gr.  \  (or  0.016  gm.)  atropine 

sulphate,  gr.  t<jo  to  eV  (or  0.00065  to  0.001  gm.)  and 
nitroglycerin,  gr.  jfa  to  A  (or  0.00065  to  0.001  gm.) 
subcutaneously  at  once. 

3.  Unless  improvement  begins  promptly,  the  nitroglycerin 

should  be  repeated,  and  venesection  may  be  required. 

4.  The  following  drugs  may  be  of  service. 


By  inhalation: 


Amyl  nitrite:  5  m.  (or  0.3  c.c). 


By  mouth: 


Subcutaneously : 

Intravenously: 
5 


1  drach.  (or 


oz. 


Spiritus  ammonise  aromaticus:    1  drach.  (or 

4  c.c). 
Spiritus  setheris  compositus :  * 

4  c.c). 
Whiskey  or  brandy:  from  4  drach.  to  1 

(or  15  to  30  c.c). 
(Cocaine  hydrochloride:  \  gr.  (or  0.016  gm.); 
(     said  to  be  dangerous. 
Strophanthin:  dangerous  (p.  197). 
Do  not  attempt  to  transport  the  patient  until  immediate 
danger  has  passed. 

6.  Rest  in  bed  is  advisable  for  a  few  days  to  allow  the 

heart  to  recover  itself. 

7.  Digitalis,  purgation,  etc.,  may  be  needed. 

8.  Subsequent  regulation  of  life  is  essential  to  avoid  re- 

currence. 

Pulmonary  Edema  without  Hypertension.  Pulmonary  edema 
may  appear  in  cardiac  insufficiency  from  any  cause.  It  is 
common  in  mitral  stenosis,  but  seldom  acute  enough  to  require 
special  treatment.  When  severe  it  should  be  treated  as  in  hy- 
pertension, except,  that  the  blood-pressure  being  normal  or  low, 
nitrites  are  of  doubtful  value  and  may  perhaps  do  harm. 


Hoffmann's  anodyne." 


31 


Pulmonary  edema  occurs  also  in  infectious  diseases.  In  pneu- 
monia it  may  be  very  acute,  but  is  not  necessarily  of  cardiac 
origin.  For  treatment  see  p.  33;  also  "Typhoid  Fever,"  pp. 
71,  75,  and  "Pneumonia,"  p.  125. 

CIRCULATORY   DISORDERS   IN   THE  INFEC- 
TIOUS  DISEASES. 

Note.  —  Common  in  acute  infections,  particularly  in  pneu- 
monia and  in  septic  states.  The  circulatory  disturbances  may 
be  attributed  to  one  of  the  following  causes  or  to  a  combination 
of  them. 

A.     CAUSES. 

1.  Faulty  innervation  of  the  heart  due  to  toxemia. 

2.  Cloudy  swelling  of  myocardium  due  to  toxemia. 

3.  Ill-nourished    myocardium    secondary    to    emaciation    or 

anemia. 

4.  Infection  of  the  valves,  myocardium  or  pericardium. 

5.  Lesions  obstructing  the  pulmonary   circulation,   e.g.,   em- 

bolism of  the  pulmonary  artery  or  of  its  large  branches. 

6.  Vascular  relaxation  due  to  toxemia. 

B.     TREATMENT   IN   GENERAL. 

1.  Dilute,  eliminate  or  neutralize  toxins. 

2.  Minimize  exertion. 

3.  Prevent  abdominal  distension. 

4.  Strive  to  maintain  nutrition. 

5.  Emaciated  patients,  capable  of  taking  little  food,  some- 
times do  well  on  large  doses  of  alcohol  which  seem  to  act  for 
them  as  a  food  and  indirectly  as  a  stimulant. 

6.  Cardiac  stimulants  must  often  be  tried  empirically  from 
lack  of  a  precise  diagnosis  or  as  a  last  hope.  They  often  fail  to 
do  good. 

C.     TREATMENT  IN  PARTICULAR. 

I.     Cardiac  Disorders. 

1.  Faulty  Innervation.  Alcohol,  digitalis,  strychnine  or  ice- 
bag,  etc.,  may  be  tried  but  are  not  likely  to  avail  much. 

2.  Cloudy  Swelling.  Digitalis,  caffeine  or  camphor  may  be 
tried. 


33 


3.  Ill-nourished  Myocardium  demands  improved  nutrition  of 
the  patient.     Alcohol  and  stimulants  may  perhaps  help. 

4.  Cardiac  Infection.  Treat  as  for  active  infectious  endo- 
carditis, p.  23. 

5.  Obstruction  in  the  Lung.     As  a  rule  nothing  can  be  done. 

6.  Pulmonary  Edema  occasionally  yields  promptly  to  atropine, 
used  subcutaneously.  Cardiac  stimulants  or  strophanthin 
{dangerous,  p.  197)  may  be  tried.  Venesection  may  do  good  if  the 
edema  be  attributable  directly  to  cardiac  dilatation. 

II.     Vascular  Relaxation:     "  Vasomotor  Paresis." 

Notes.  —  The  relaxation  is  believed  to  be  the  result  of  the 
action  of  toxins  on  nerves  or  blood-vessels.  It  occurs  occasionally 
in  severe  infections,  particularly  in  typhoid  and  in  pneumonia. 
The  condition  is  analogous  to  surgical  shock  although  its  cause 
is  not  the  same. 

The  onset  may  be  gradual  or  rapid.  It  can  be  observed,  by 
watching  the  development,  that  the  pulse  becomes  weak  while 
the  heart-sounds  are  still  of  good  quality.  Later,  as  a  result  of 
low  peripheral  pressure  and  meager  return  of  blood  to  the  heart, 
the  heart's  action  becomes  more  and  more  rapid,  the  sounds 
fainter  and  perhaps  irregular.  Finally,  the  extremities  become 
cold,  the  face  pale  and  the  pulse  imperceptible. 

Principles  of  Treatment.  Promote  return  of  blood  to  the 
heart  by: 

(a)  Filling  the  vessels,  or  by 

(b)  Constriction  of  vessels. 

Methods:  1.  Salt  solution  used  by  hypodermoclysis  is  rap- 
idly absorbed  and  generally  acts  well  in  from  five  to  fifteen  min- 
utes. It  may  save  life  even  when  the  patient's  condition  is  very 
bad.  A  pint,  heated  to  blood-temperature,  should  be  used  at 
a  time.  It  may  be  repeated  in  an  hour  or  later  if  needed.  The 
administration  of  frequent  doses  of  salt  solution  in  this  way  may 
lead  to  cardiac  dilatation  unless  excretion  be  rapid. 

Salt  solution  may  be  given  intravenously  in  very  critical  con- 
ditions. 

When  the  need  for  salt  solution  can  be  anticipated  the  means 
of  administering  it  should  be  kept  in  readiness. 


35 


2.  Direct  transfusion  of  blood  might  be  tried  if  it  could  be 
done  without  delay. 

3.  Adrenalin  chloride  is  a  very  powerful  vaso-constrictor  but 
very  transient  in  its  effect.  It  is  difficult  to  get  satisfactory 
results  with  it. 

Pituitrin  has  an  effect  on  blood-pressure  like  adrenalin,  but 
milder  and  less  transient.     It  may  be  tried  safely. 

Caffeine  sodio-salicylate,  3  gr.  (or  0.2  gm.),  may  be  tried  sub- 
cutaneously,  but  is  not  very  effective  as  a  vaso-constrictor. 


ANGINA   PECTORIS. 

Definition.  Pain  or  distress  attributable  to  spasm,  or  to 
occlusion,  of  a  coronary  artery. 

Spasm  is  generally  associated  with  syphilitic  or  degenerative 
change  in  the  vessel-wall,  but  lesions  may  be  confined  to  other 
parts  of  the  heart  or  to  the  aorta,  and  "neurotic  angina,"  in 
which  there  is  no  known  lesion,  is  rather  common.  Occlusion 
may  be  thrombotic  or  embolic. 

Angina  may  be  indicative  of  threatened  exhaustion  or  of  de- 
ficient blood-supply  to  the  myocardium. 

Etiological  Classification  of  Angina  Pectoris. 

1.  Syphilitic:  common  in  men  of  early  middle  age. 

2.  Degenerative  or  arteriosclerotic:  common  in  old  men. 

3.  Embolic:  seen  in  endocarditis  or  intracardiac  thrombosis. 

4.  Neurotic:  common  in  young  women. 

DIAGNOSIS. 

An  accurate  history  of  the  mode  of  onset,  duration  and  radi- 
ation of  the  pain  and  the  discovery  of  an  adequate  background 
for  the  disease  is  of  the  greatest  importance.  Pain  on  exertion 
suggests  angina.  Angina  in  a  young  or  middle-aged  man  suggests 
syphilis. 

A  complete  physical  examination  may  show  nothing  important. 

Angina  in  a  young  woman  suggests  psychic  trauma. 

Painless  angina,  otherwise  typical,  is  seen  rarely. 

I.     SYPHILITIC   ANGINA. 

Pathology.  Syphilitic  changes  in  the  aorta,  aortic  valves  or 
coronary  arteries,  diminishing  their  circulation  are  generally 
demonstrable. 

Etiology.  A  late  manifestation  of  syphilis;  commonest  in 
middle  life. 

Prognosis.     The  prognosis  is  very  uncertain. 


39 


A.    Treatment  in  General. 

1.  Antisyphilitic  measures.* 

2.  Regulation  of  life  to  reduce  demands  on  the  heart  to  what 
it  can  meet  is  of  the  utmost  importance. 

(a)  Avoid  anything  known  to  bring  on  angina  in  the 

individual,  e.g.}  exercise  after  meals. 
(6)  Avoid  physical  and  mental  strain. 

(c)  Avoid  distention  of  the  stomach  and  bowels. 

(d)  Food  and  liquids  should  be  taken  in  moderation. 

(e)  Tobacco  and  alcohol  in  great  moderation  if  at  all. 
(/)  Bowels  should  be  kept  free. 

3.  Cardiac  insufficiency,  if  present,  requires  appropriate  treat- 
ment on  general  principles. 

4.  Small  doses  of  digitalis  often  help  to  reduce  the  number 
of  attacks  even  when  the  usual  signs  of  cardiac  insufficiency 
are  absent.  Theobromine  sodio-salicylate,  grs.  5  t.i.d.,  or 
barium  chloride,  grs.  iV  t.i.d.,  may  be  tried  for  the  same  purpose. 

5.  At  the  first  sign  of  an  attack  the  patient  should  take  nitro- 
glycerin (p.  197)  or  amyl  nitrite,  repeat  it  in  a  few  minutes  if  not 
relieved  and  remain  quiet  for  a  time  after  the  attack  has  passed. 
An  expected  attack  can  sometimes  be  prevented  by  timely  use 
of  nitroglycerin.  The  drug  must  be  always  accessible  with- 
out effort.  Nitroglycerin  should  be  chewed  and  absorbed  in 
the  mouth  and  amyl  nitrite  taken  by  inhaling  it  from  a  hand- 
kerchief. It  is  important  to  provide  pearls  which  break  easily 
but  not  spontaneously  if  amyl  nitrite  is  to  be  used. 

B.    Treatment  of  Anginal  Attacks. 

If  called  to  treat  an  attack  of  angina  use  nitroglycerin  sub- 
cutaneously  or  amyl  nitrite  or  both  immediately.  Repeat  the 
dose  in  a  few  minutes  if  the  patient  is  not  relieved.  If  nitro- 
glycerin gives  no  effect  in  repeated  doses  amyl  nitrite  may  per- 
haps relieve.  If  the  pain  is  unusually  severe  and  obstinate 
morphine  may  be  injected. 

Do  not  attempt  to  transport  the  patient  and  do  not  allow  him 
to  make  the  slightest  exertion  for  a  time  after  the  symptoms 
have  passed.     Rest  in  bed  is  advisable  after  a  severe  attack. 

That  which  is  known  to  bring  on  an  attack  must  be  avoided. 

*  It  is  doubtful  whether  Salvarsan  should  be  used  in  the  presence  of  severe 
cardiac  disease. 


41 


II.     DEGENERATIVE  ANGINA. 

Pathology.  Coronary  sclerosis  and  chronic  myocardial  degen- 
eration, with  or  without  fibrous  myocarditis,  will  often  be  demon- 
strable as  part  of  a  widespread  arteriosclerosis. 

Prognosis.  Years  of  life  may  be  possible  but  sudden  death 
may  occur  at  any  time. 

Treatment.  1.  Regulate  life  to  avoid  strain. 

2.  When  there  is  any  cardiac  insufficiency  the  patient  should 
take  digitalis  and  salts  for  long  periods.  The  dose  required  for 
the  individual  must  be  determined  carefully  by  trial. 

3.  Digitalis,  theobromine,  potassium  iodide  or  barium  chloride 
in  small  doses  may  limit  the  number  of  attacks  or  even  prevent 
them. 

4.  If  an  old  syphilis  be  suspected  give  potassium  iodide  and 
protiodide  of  mercury  in  moderate  doses. 

5.  The  treatment  for  the  attack  is  the  same  as  in  syphilitic 
angina. 

III.     EMBOLIC   ANGINA. 

Vaso-dilators  are  likely  to  give  little  relief.  Morphine  is 
usually  required  in  large  doses.  (Death  may  come  suddenly  at 
onset  of  symptoms.) 

IV.     NEUROTIC     ANGINA. 

Pathology.     No  characteristic  changes  recognized. 

Etiology.  Commonly  due  to  excess  in  tea,  coffee,  or  tobacco, 
to  fear  or  emotional  shock  and  often  associated  with  debility. 
It  is  seen,  almost  exclusively,  in  neurotic  young  women. 

Prognosis.  Death  is  not  to  be  expected  and  the  chance  of 
complete  cure  is  excellent. 

Treatment.     1.  Remove  the  cause  when  possible. 
2.  General  hygienic  measures. 

By  these  means  recurrence  can  be  prevented. 

The  attack  is  generally  too  brief  and  mild  to  require  treat- 
ment, but  when  severe,  it  should  be  treated  like  organic  angina. 


CHAPTER    II. 


NEPHRITIS. 

CLASSIFICATION. 

1.  Acute  Renal  Irritation.  1 

2.  Acute  Nephritis.  f  Allied  Conditions. 

3.  Chronic  Nephritis.  J 

4.  Syphilitic  Nephritis. 

5.  Arteriosclerotic  Degeneration. 

6.  Passive  Congestion. 

NOTES   ON   CLASSIFICATION. 

This  classification  aims  to  separate  only  the  more  important 
types  of  nephritis  which  can  be  recognized  clinically  and  which 
require  different  treatment. 

Acute  renal  irritation,  acute  nephritis  *  and  chronic  nephritis 
appear  to  be  allied  diseases,  The  gaps  between  them  are  bridged 
by  intermediate  forms  and  the  acute  infectious  diseases  are 
responsible  for  most  cases  of  these  three  types  of  renal  inflam- 
mation. Toxic  irritation  differs  from  acute  nephritis  mainly 
in  degree,  and  chronic  nephritis  from  acute  nephritis  in  that 
instead  of  recovering  it  progresses,  though  it  may  be  slowly. 

Although  arteriosclerotic  degeneration  is  essentially  different 
from  chronic  nephritis,  the  latter  being  primarily  an  inflammation 
of  the  kidney  and  the  former  being  a  degeneration  secondary  to 
vascular  disease,  the  two  are  often  combined.  In  such  com- 
binations either  process  may  predominate. 

Besides  intermediate  or  mixed  forms  of  nephritis  there  are  the 
rare  amyloid  degeneration  and  a  variety  of  forms  difficult  to 
classify. 

*  The  recent  work  of  H.  Cabot  and  Crab  tree  seems  to  show  that  glomerular 
nephritis  is  caused  by  the  streptococcus  viridans. 

43 


45 


RECOGNITION    OF   TYPES    OF   NEPHRITIS. 

Acute  Renal  Irritation  is  distinguished  from  acute  nephritis 
by  less  profound  changes  in  the  urine,  absence  of  symptoms  of 
renal  insufficiency  and  prompt  recovery  after  removal  of  the 
cause.     It  is  frequently  symptomatic  in  acute  fevers. 

Acute  Nephritis  *  is  common  in  childhood  and  youth.  It  is 
generally  traceable  to  an  acute  infectious  disease,  is  often  found 
after  scarlet  fever  and  may  follow  tonsillitis  or  result  from  an 
irritant  poison.  Acute  nephritis  differs  much  in  severity  and 
consequently  in  signs  and  symptoms.  Severe  cases  may  show 
anuria  or  marked  oliguria  with  anasarca  and  perhaps  uremia. 
The  urine  in  these  cases  is  loaded  with  blood,  albumen,  casts 
and  fat,  and  that  of  mild  conditions  contains  the  same  elements  in 
smaller  amount.  Blood-pressure  may  be  moderately  elevated, 
and  if  the  disease  persists  for  some  weeks,  left  ventricular 
hypertrophy  may  develop. 

Chronic  Nephritis.  The  etiology  is  like  that  of  acute  neph- 
ritis, as  a  rule,  but  there  are  some  cases  arising  from  chronic 
toxemias. 


Stages.     1.  Early.       )  T 

I      _,  a.  Latent. 


b.  Exacerbation. 


2.  Subacute.  Y     Phases. 

3.  Chronic. 
The    course  of  the  disease  may  run  from  a  few  years  or  less  to 

twenty  years  or  more.  Any  stage  may  be  without  symptoms. 
The  early  stage  may  be  indistinguishable  from  acute  nephritis, 
and  exacerbations  may  be  mistaken  for  acute  nephritis.  Left 
ventricular  hypertrophy  and  hypertension  develop  gradually 
and  there  is  a  progressive  fall  in  the  specific  gravity  of  the  urine 
associated  with  an  increase  in  the  amount  of  urine. 

The  late  stage  shows  marked  left  ventricular  hypertrophy,  a 
blood-pressure  generally  over  200  mm.  of  mercury  and  a  urine 
of  very  low  gravity,  containing  little  or  no  albumen  and  a  scanty 
sediment.  At  this  stage  many  of  the  glomeruli  and  much  of 
the  parenchyma  has  been  replaced  by  connective  tissue,  and 
shrinkage  has  followed  so  that  the  .kidneys  are  much  diminished 
in  size.     The  chief  dangers  are  from  uremia  or  from  cardiac 


*  The  acute  nephritis  produced  by  the  irritant  poisons  such  as  corrosive 
sublimate  is  of  the  tubular  variety,  whereas  that  of  the  acute  infections  is  of 
the  glomerular  type  and  is  caused  by  a  streptococcus. 


47 


insufficiency  secondary  to  hypertension.  In  the  absence  of 
arteriosclerosis  a  provisional  diagnosis  of  chronic  nephritis  may 
often  be  made  by  the  evidence  of  hypertension  and  of  cardiac 
hypertrophy.  Cases  of  chronic  nephritis  complicated  with  ar- 
teriosclerosis are  liable  to  apoplexy. 

Syphilitic  Nephritis  is  generally  regarded  as  an  unusual  form 
of  acute  nephritis.  It  occurs,  according  to  Osier,  most  commonly 
in  the  secondary  stage  of  syphilis  within  six  months  of  the  pri- 
mary lesion  and  it  resembles  glomerular  nephritis.  Gumma 
of  the  kidney  is  rarely  seen  but  it  is  probable  that  some  instances 
of  renal  arteriosclerosis  are  of  syphilitic  origin.  Signs  of  an 
active  syphilis  in  the  presence  of  a  nephritis  suggest  but  do  not 
prove  that  the  two  are  related. 

Arteriosclerotic  Degeneration  of  the  kidney  is  most  common  in 
old  age.  It  may  be  part  of  a  widespread  arteriosclerosis  or  it 
may  be  manifested  chiefly  in  the  kidney.  There  occurs  a  non- 
inflammatory destruction  of  parts  of  the  kidney  dependent  on 
sclerosis  of  the  arteries  supplying  those  parts.  Local  shrinkage 
and  irregularity  or  roughness  of  the  surface  results. 

The  urine,  at  first,  may  show  considerable  albumen  and  some 
blood  and  casts.  Later  it  resembles  that  of  chronic  nephritis. 
Hypertension  and  left  ventricular  hypertrophy  are  generally 
well  marked  in  the  later  stages  of  renal  degeneration. 

The  greatest  dangers  are  from  cardiac  insufficiency  or  cerebral 
hemorrhage.  Typical  uremia  occurs  rarely  if  at  all  in  pure 
degenerative  cases  but  there  is  often  more  or  less  chronic 
nephritis  combined  with  the  degenerative  lesions.  Chronic 
lead-poisoning,  gout  or  syphilis  may  be  important  etiologically. 

Passive  Congestion  is  secondary  to  congestion  in  the  venous 
circulation.  Therefore,  it  is  commonly  symptomatic  of  car- 
diac insufficiency.  The  urine  is  high  colored,  scanty  and  of  a 
high  gravity.  Albumen  and  casts  are  found,  varying  in  amount 
and  number.  There  are  no  uremic  symptoms,  and  the  urine 
clears  rapidly  after  removal  of  the  congestion. 

Passive  congestion  may  mask  an  acute  nephritis,  especially 
in  the  active  stage  of  endocarditis. 

ACUTE  RENAL  IRRITATION. 

Treatment.  The  signs  of  irritation  can  be  much  reduced  by 
the  free  administration  of  water.     The  water  dilutes  the  irri- 


49 


tating  substance  and  promotes  excretion  by  stimulating  diuresis. 
No  other  direct  treatment  is  needed. 

Caution.     Make  sure  that  a  nephritis  is  not  developing. 

ACUTE    NEPHRITIS. 
PRINCIPLES   OF  TREATMENT. 

A.  Reduce  the  demands  on  the  kidney  by: 

1.  Rest  in  bed. 

2.  Elimination  by  other  channels.  \  „!  ~        ,. 

J  {  (6)  Sweating. 

3.  Suitable  diet. 

4.  Limitation  of  liquids  in  suitable  cases. 

B.  Maintain  nutrition. 

C.  Avoid  exposure  to  cold  or  to  sudden  cooling. 

D.  Drugs  should  be  used  only  when  indicated;  never  by 
routine. 

METHODS   OF   TREATMENT. 

Sweating.*     1.  Hot-air  bath  in  bed  or  chair. 

2.  Hot  tub-bath. 

3.  Hot  wet  pack. 

4.  Electric  light  bath. 

5.  Turkish  or  Russian  bath. 

Hot-air  baths  are  best  given  in  bed.  If  the  baths  cause 
profuse  sweating  they  may  be  used  daily  for  an  hour  or  more. 
If  sweating  does  not  begin  promptly  a  drink,  hot  or  cold,  may 
start  it,  or  pilocarpine  may  be  administered  subcutaneously. 
Pilocarpine  may  cause  pulmonary  edema  and  is,  therefore, 
contraindicated  when  the  heart  is  weak,  the  lungs  congested, 
or  the  patient  unconscious.  Some  patients  who  sweat  little  at 
first  respond  well  to  subsequent  baths. 

If  sweating  cannot  be  induced,  if  the  pulse  becomes  weak, 
or  if  the  patient  develops  cardiac  symptoms  during  a  bath 
the  baths  must  be  given  up.  They  should  not  be  ordered  for 
an  unconscious  patient  without  consideration  followed  by  close 
observation. 

Hospitals  provide  apparatus  for  the  hot-air  bath.     In  private 

*  The  value  of  sweating  is  in  dispute. 


51 


houses  it  can  be  improvised  with  barrel-hoops  or  strong  wire  to 
arch  the  bed,  an  oilcloth  from  the  kitchen  table  as  a  rubber 
sheet,  an  elbow  of  stovepipe  and  a  kerosene  lamp  to  provide 
the  heat;  or  the  patient,  without  clothing,  may  sit  in  a  cane- 
bottomed  chair  under  which  stands  a  small  lamp.  Blankets 
are  then  wrapped  around  the  chair  and  the  patient  together, 
leaving  no  hole  for  the  heat  to  escape. 

Care  must  be  taken  not  to  set  the  blankets  on  fire. 

Purgation.  Obtain  watery  catharsis  to  reduce  edema  and  to 
increase  elimination  of  toxic  material  by  the  intestinal  tract. 
Magnesium  sulphate,  or  compound  jalap  powder  with  addi- 
tional potassium  bitartrate,  or  elaterium  are  good  for  this  purpose 
(p.  201). 

In  the  absence  of  edema,  purgation  should  not  be  excessive, 
lest  the  patient's  nutrition  suffer. 

Diet.  Proteids,  meat  broths,  spices,  acids  and  alcohol  ir- 
ritate the  kidney  and  are  to  be  avoided  during  the  acute  stage. 

Milk  is  an  exception  to  the  rule  against  proteid  because  ex- 
perience shows  that  it  is  not  injurious.  A  diet  exclusively  of 
milk  becomes  monotonous  if  long  continued  and  such  large 
quantities  are  needed  to  maintain  nutrition  that  the  fluid  part 
may  tend  to  increase  edema.* 

Salt  seems  not  to  be  harmful  as  a  rule.  When,  however, 
edema  persists  in  spite  of  other  treatment,  a  "  salt-free  "  diet 
may  be  tried,  i.e.,  salt  is  not  to  be  added  to  food  either  before  or 
after  cooking.  This  change  is  followed  occasionally  by  rapid 
disappearance  of  the  edema.  If  deemed  advisable  the  phos- 
phate! in  milk  can  be  precipitated  by  adding  5  grs.  (or  0.3  gm.) 
of  calcium  carbonate  per  pint  of  milk. 

Diet  List  (incomplete).  Milk,  cream,  butter,  sugar,  junket, 
ice  cream,  bread,  toast,  cereals,  rice,  potato,  macaroni,  sago, 
tapioca,  spinach,  lettuce,  sweet  raw  fruits  or  stewed  fruits. 

In  convalescence  enlarge  diet  cautiously  on  account  of  danger 
of  relapse.  When  returning  to  proteid  foods  allow  eggs  first, 
then  fish  and  lastly  meat,  red  or  white. 


*  Three  quarts  of  milk  furnish  about  2000  calories  which  is  scant  for  an 
adult. 

t  One  liter  of  milk  contains  3.80  gm.  of  phosphate  and  1.79  gm.  of  chlorides; 
Sommerfeld,  "Handb.  d.  Milchkunde,"  p.  271. 


53 

Liquids,  including  liquid  foods,  should  be  limited  strictly 
when  there  is  anasarca  or  when  they  are  not  being  fully  excreted. 
One  pint  in  twenty-four  hours  may  be  enough.  Cracked  ice 
may  be  used  for  thirst,  but,  if  the  patient  suffers,  more  liquid 
should  be  allowed. 

Water  is  an  excellent  diuretic  when  freely  excreted.  It 
dilutes  irritating  substances  and  favors  their  elimination. 

Nutrition.  The  quantity  of  food  to  be  prescribed  depends  on 
the  severity  of  the  nephritis,  the  physical  strength,  and  the  state 
of  nutrition  of  the  patient.  Strong,  well-nourished  patients 
having  severe  nephritis  may  benefit  by  fasting  for  a  day  fol- 
lowed by  very  small  quantities  of  food  for  several  days.  A 
feeble,  emaciated  and  anemic  person  should  receive  food  enough 
to  maintain  body-weight. 

Exposure.  To  prevent  chill,  keep  room  at  equable  tempera- 
ture and  let  patient  wear  flannel  or  lie  between  blankets. 

Medication.  Irritating  diuretics,  such  as  calomel,  are  danger- 
ous in  all  forms  of  nephritis. 

Theobromine,  theocine  and  apocynum  are  useless  and  may 
perhaps  do  harm  in  acute  nephritis. 

Mild  saline  diuretics  or  alkaline  mineral  waters  may  be  valu- 
able, particularly  in  convalescence,  but  it  may,  perhaps,  be 
wiser  to  avoid  them  in  severe  cases  during  the  early  stage. 

For  anemia,  iron  may  be  tried,  e.g.,  Blaud's  Pill,  or  Basham's 
Mixture  (Liquor  ferri  et  ammonii  acetatis  N.  F.)  which  con- 
tains iron  and  acts  also  as  a  mild  diuretic. 

Prophylaxis.  If  it  appears  that  the  tonsils  were  the  point 
of  entrance  or  the  original  seat  of  disease  their  removal  at  a 
suitable  time  should  be  advised. 

Uremia.    For  treatment  see  p.  59.    / 


55 

CHRONIC    NEPHRITIS. 

PRINCIPLES    OF   TREATMENT. 

1.  Adequate  nourishment  is  essential  because  the  disease  is 
chronic  and  a  cure  not  to  be  expected. 

2.  Limit  demands  on  the  kidney  and  guard  against  uremia 
by  (a)  diet,  (6)  elimination. 

3.  Guard  against  cardiac  insufficiency  by  avoiding  physical 
and  mental  strain. 

4.  Avoid  exposure  to  cold. 

METHODS. 

Methods  are  the  same  in  general  as  for  acute  nephritis,  but 
they  must  be  applied  with  regard  to  the  condition  of  the  patient 
and  the  stage  and  severity  of  the  disease. 

Avoid  unnecessary  restrictions. 

The  Early  Stage,  when  severe,  must  be  treated  as  acute 
nephritis  until  recognized  as  chronic.  Nutrition  then  becomes 
a  more  important  problem. 

Exacerbations  are  treated  like  acute  nephritis  except  that 
nutrition  is  more  important  than  in  acute  nephritis  and  therefore 
diet  should  be  more  liberal. 

Latent  phase:  early,  subacute,  or  chronic: 

1.  Restrict  more  or  less  the  following: 

(a)  Meats.  (d)  Alcohol. 

(b)  Meat  broths.  (e)  Acids. 

(c)  Spices.  (/)  Salt. 

2.  To  favor  elimination  of  toxic  material  the  following  may 
be  advised: 

(a)  A  saline  cathartic  every  second,  third,  or  fourth  day. 

Bowels  must  be  kept  free. 
(6)  Hot    tub-baths,    Russian,    or    Turkish    baths    twice 

weekly, 
(c)  Alkaline  mineral  waters  with  meals. 

3.  Uremia.     For  treatment  see  p.  59. 

4.  Cardiac  Insufficiency  demands  prompt  recognition  and 
treatment.     It  results  commonly  from  hypertension,  p.  27. 


57 


SYPHILITIC  NEPHRITIS. 

1.  Apply  principles  advised  for  acute  or  chronic  nephritis 
according  to  the  severity  and  symptoms  of  the  case. 

2.  Iodide  and  mercury  or  salvarsan  should  be  used  in  small 
doses. 

5.  Watch  urine  and  omit  mercury  if  renal  irritation  increases 
under  treatment.  When  the  diagnosis  is  correct  the  urine 
generally  improves  promptly.  As  there  are  no  characteristic 
signs  mistakes  of  diagnosis  easily  occur. 

ARTERIOSCLEROTIC  RENAL  DEGENERATION. 
TREATMENT. 

1.  Search  for  a  cause  of  arteriosclerosis.  If  such  can  be  found 
and  if  it  is  believed  still  to  be  operative  treat  it  appropriately. 

Such  causes  are,  e.g.,  (a)  chronic  lead-poisoning;  (6)  gout; 
(c)  syphilis;    (d)  prolonged  worry. 

2.  Nutrition  must  be  maintained. 

3.  Limit  the  demands  on  the  kidney  by  moderate  restriction 
of: 

(a)  Meats.  (d)  Alcohol. 

(6)  Meat  broths.  (e)  Acids. 

(c)  Spices. 

4.  Avoid  physical  and  mental  strain  to  guard  against  (a) 
cardiac  insufficiency;    (6)  cerebral  hemorrhage. 

5.  Cardiac  insufficiency,  when  present,  should  be  treated  with 
reference  to  its  probable  cause,  e.g.: 

(a)  Degenerative  valve  lesion,  p.  25. 

(6)  Degenerative  myocardial  lesion,  p.  41. 

(c)  Hypertension,  p.  27. 

6.  Mild  toxemia  may  clear  up  under  cardiac  treatment  if  the 
heart  is  at  fault. 

Alkaline  diuretics  may  be  of  use. 

Methods  advised  for  uremia  may  be  used  if  toxemia  be  severe. 

PASSIVE    CONGESTION    OF    THE   KIDNEY. 

The  treatment  is  that  of  the  cause  of  the  stasis. 


59 


UREMIA. 

Note.  —  Uremia  is  an  intoxication  of  unknown  nature,  common 
in  severe  acute  nephritis  and  in  chronic  nephritis,  and  par- 
ticularly so  in  exacerbations  of  the  subacute  stage  of  chronic 
nephritis. 

Symptoms  vary  much  in  degree.  There  may  be  mental 
sluggishness,  drowsiness  or  coma,  loss  of  appetite,  nausea  or 
vomiting,  muscular  twitchings  or  convulsions,  headache,  delir- 
ium, disturbance  of  vision,  transient  ocular  paralysis,  paresis  of 
the  extremities  or  paroxysmal  dyspnoea.  The  urine  is  usually 
scanty  or  suppressed.  Retinitis  and  Cheyne-Stokes  respiration 
are  common.  The  onset  may  be  gradual,  and  with  slight  signs, 
or  relatively  acute  and  severe.     Edema  may  be  present  or  absent. 

Methods  of  Treatment. 
For  mild  uremia: 

1.  Diet  as  for  mild  acute  nephritis. 

2.  Eliminative  measures. 

(a)  Purgation. 
(6)  Sweating.* 

(c)  Water  if  there  is  little  or  no  edema. 

(d)  Saline  diuretics. 

3.  Cardiac  stimulation  is  essential  if  there  is  any  insufficiency. 
Severe  uremia: 

1.  Diet  should  be  much  restricted  in  quantity  and  quality  as 
for  severe  acute  nephritis.  Vomiting  or  unconsciousness  may 
prevent  feeding  for  a  time. 

2.  Water  should  be  administered  freely  unless  there  be  much 
edema.  If  water  cannot  be  taken  by  mouth  it  can  be  used  as 
salt-solution  by: 

(1)  Hypodermoclysis. 

(2)  Intravenously. 

(3)  By  rectum,  (a)  Enema. 

(6)  Seepage. 

*  Sweating  is  said  to  do  harm  in  some  cases.  I  believe,  however,  that  it 
generally  does  good  in  some  way  not  yet  understood. 


61 


3.  Purgation.  Magnesium  sulphate,  or  other  purgatives  (p. 
201)  may  be  used.  Croton  oil  is  useful  especially  for  uncon- 
scious patients.  If  rubbed  up  with  a  little  butter,  made  into 
a  ball  and  placed  on  the  back  of  the  tongue,  it  will  be  swallowed. 
Repeated  doses  of  purgatives  should  be  employed,  if  needed, 
to  obtain  prompt  and  profuse  watery  catharsis,  but  when  there 
is  no  edema,  excessive  purgation  may  tend  to  concentrate  toxins, 
and  may  thus  do  harm,  unless  counteracted  by  free  administration 
of  water. 

4.  Sweating  seems  to  do  good.  Hot-air  baths  may  be  used 
daily  if  they  cause  profuse  sweating.  They  should  not  be  or- 
dered for  an  unconscious  patient.  Pilocarpine  should  not  be 
used  if  there  is  pulmonary  edema,  cardiac  insufficiency  or  un- 
consciousness. 

5.  Venesection.  A  pint  or  more  of  blood  may  be  withdrawn 
from  a  vein  at  the  elbow  by  incision,  or,  if  a  suitable  apparatus 
be  at  hand,  by  aspiration. 

Opinion  is  divided  as  to  the  need  or  value  of  injecting  salt 
solution  after  bleeding.  Ordinarily,  patients  do  well  without 
it. 

6.  Colon  irrigations  with  large  quantities  of  hot  water  may 
be  tried  in  the  hope  of  promoting  elimination  of  toxins. 

7.  Drugs.  The  use  of  nitroglycerin  or  other  vaso-dilators 
is  followed  frequently  by  pronounced  diuresis  in  patients  having 
hypertension.     The  effect  is  transient. 

Morphine  may  be  given  subcutaneously  for  convulsions. 

Saline  diuretics,  e.g.  "  Cream  of  tartar  water,"*  Pot.  citrate, 
or  "  Basham's  mixture,"  may  be  of  use  when  the  severe  symp- 
toms have  subsided. 

Heart  stimulants  are  required  when  there  is  any  cardiac  insuffi- 
ciency, p.  13. 


*  A  sat.  sol.  of  Pot.  bitartrate,  the  strength  of  which  is  1  in  201,  equal  to 
about  40  grs.  in  a  pint,  or  to  3  gm.  in  500  c.c.  of  water.  Lemon  juice  or  lemon 
peel  can  be  used  for  flavoring. 


CHAPTER    III. 


ACUTE   INFECTIOUS   DISEASES. 
PRINCIPLES    OF    TREATMENT. 


1.  Rest  in  bed 


u 

lb. 


To  conserve  strength. 

To  reduce  metabolic  waste. 


2.  Ingestion  of  much  water 


it 


5.  Bowels  should  be  kept  clear 


To  dilute  toxins. 

To  favor  their  elimination. 

a.  To  favor  digestion. 

b.  To  prevent  absorption  of 

toxic  substances. 


6.  Good  nursing 


5.  Diet  should  be 


6    Meals  should  be 


a.  To  secure  cleanliness. 

b.  To  conserve  strength. 

c.  To  promote  comfort. 

d.  To     afford     accurate     information    to 

physician. 

e.  To  facilitate  treatment. 

a.  Easy  to  swallow. 

b.  Easily  digestible. 

c.  Nutritious  but  not  bulky. 

d.  Palatable  and  varied. 

a.  Frequent  and  small  to  favor  diges- 
tion. 

b.  Commensurate     in     quantity     with 
digestive  power. 


7.  The  sick-room  should  be  well  ventilated. 

8.  Infection  of  others  must  be  prevented. 

9.  Symptoms  should  be  treated  as  they  arise  with  regard 
to  the  circumstances  of  the  case. 

63 


65 

TYPHOID    FEVER. 

Notes.  —  Typhoid  is  characterized  pathologically  by  peculiar 
ulceration  of  the  small  intestines.  Ulceration  is  less  frequent 
in  the  colon  and  is  rare  in  the  rectum. 

Typhoid  bacilli  enter  the  blood,  the  organs,  the  secretions, 
and  the  excretions. 

The  disease  is  self-limited,  lasting  from  two  weeks  to  three 
months.  Relapses  are  common  and  complications  frequent. 
Toxemia  is  often  severe. 

COMMON   CAUSES   OF  DEATH. 

1.  Toxemia. 

2.  Exhaustion. 

3.  Severe  complications. 

(a)  Perforative  peritonitis. 
(6)  Repeated  hemorrhages. 

PRINCIPLES    OF  TREATMENT  FOR   TYPHOID. 

A .  Prevent  infection  of  others. 

B.  Dilute  toxins  and  favor  their  elimination. 

C.  Conserve  strength  of  the  patient. 

D.  Diet  should  be  suited  to  the  individual  as  well  as  to  the 
disease. 

E.  Drugs  are  to  be  prescribed  for  definite  reasons  only  and  not 
to  reduce  the  fever. 

F.  Observe  the  patient's  condition  closely  and  modify  treat- 
ment promptly  when  indicated. 

G.  Have  the  best  nursing  available  and  if  possible  have  a 
day-nurse  and  a  night-nurse. 

H.  Treat  symptoms  and  complications  with  due  regard  to 
other  circumstances  of  the  case. 

ROUTINE  ORDERS  TO  NURSE. 

1.  Enteric  precautions. 

2.  Dr.  Shattuck's  enteric  diet.     (Prof.  F.  C.  Shattuck.) 

3.  Baths  as  directed  every  four  hours,  p.r.n. 

4.  Suds  enema  every  other  day  or  p.r.n. 

5.  Spray  throat  and  wash  mouth  and  eyes  every  four  hours. 

6.  Hexamethylenamine,  5  grs.  (or  0.3  gm.)  t.i.d. 


67 


7.  Record  temperature,  pulse  and  respiration  every  four  hours, 
the  daily  excretion  of  urine,  and  the  amount  of  food  and  water 
ingested. 

Specific  directions  for  diet  and  baths  should  be  given  with 
due  regard  for  the  circumstances  of  each  case.  Frequent  modi- 
fication may  be  required. 

METHODS   OF  TREATMENT  FOR   TYPHOID. 

A.  Prophylaxis. 

I.  Prophylactic  inoculation  should  be  required  for  those  com- 
ing into  intimate  contact  with  the  patient  (p.  215). 

II.  "  Enteric  precautions." 

1.  Isolation  of  the  patient  is  desirable. 

2.  Flies  must  be  excluded. 

3.  Those  who  touch  the  patient  should  wash  their  hands 

promptly. 

4.  Eating  utensils  should  be  reserved  exclusively  for  the 

patient  and  washed  and  kept  apart. 

5.  Sheets  and  other  linen  when  removed  from  the  sick- 
room should  be  soaked  in  5  per  cent  carbolic  acid 
for  at  least  half  an  hour,  or  boiled. 

6.  The  best  method  of    dealing  with  faeces  *  is  that  of 

Kaiser.  "  It  consists  of  adding  enough  hot  water 
to  cover  the  stool  in  the  receptacle  and  then  adding 
about  J  of  the  entire  bulk  of  quicklime  (calcium 
oxide),  covering  the  receptacle  and  allowing  it  to 
stand  for  two  hours." 

Urine  can  be  treated  similarly  by  adding  enough 
quicklime  to  bring  it  to  a  boil. 

7.  Bath  water  may  be  boiled  after  using  when  practicable, 

but  this  is  not  worth  while  where  plumbing  is  good. 

8.  Cleanliness  of  the  attendant  is  essential. 

B.  Dilution  and  Elimination  of  Toxins. 

1.  The  urinary  output  should  be  kept  above  60  oz.  in  24 
hours  by  free  administration  of  water.  A  much  larger  quantity 
of  urine  can  be  obtained  but  it  is  a  question  whether  water 
taken  in  very  large  quantities  may  not  favor  hemorrhage.  Li- 
quids, including  liquid  foods,  should  total  about  three  quarts  daily. 

*  H.  Linenthal:  Monthly  Bui.  Mass.  State  Board  of  Health,  Jan.,  1914. 


69 


2W  The  bowels  should  be  kept  clear.  If  they  do  not  move 
freely  suds  enemata  may  be  employed  as  often  as  necessary. 
Cathartics  are  to  be  avoided  as  a  rule  during  the  ulcerative  stage 
because  excessive  peristalsis  may  favor  hemorrhage  or  perfor- 
ation. 

C.  Conservation  of  Strength.     Very  important  because  of  the 

long  average  duration  of  typhoid. 

1.  The  nurse  should  feed  the  patient,  turn  him  over,  allow 
him  to  do  nothing  for  himself  and  should  make  him  comfortable. 

2.  The  maximum  of  nutrition  should  be  maintained  by  fre- 
quent feedings. 

3.  Visitors  should  be  excluded  entirely  as  a  rule. 

D.  Diet. 

Dr.  Shattuck's  principle  in  choosing  a  diet  has  been  stated 
by  him  as  follows:  "Feed  with  reference  to  digestive  power 
rather  than  name  of  disease,  avoiding  such  articles  of  diet  as 
might  irritate  ulcerated  surfaces." 

Requirements : 

1.  Nutritious  but  not  bulky. 

2.  Easily  digestible. 

3.  Non-irritating  to  intestine. 

4.  Quantity  commensurate  to  digestive  power. 

5.  Adapted  to  the  patient's  condition. 

6.  Palatable  and  varied. 

Meals  should  be  frequent,  at  least  once  in  four  hours.  If 
the  patient  can  take  little  at  a  time  he  should  be  fed  every  two 
hours  or  even  every  hour. 

Diet  List.  An  enteric  diet  may  include  the  following  foods 
and  any  others  that  conform  to  the  requirements  stated  above: 
liquid  foods,  strained  cereals,  custard,  blancmange,  junket,  simple 
ice  cream,  soaked  toast  without  the  crust,  bread  or  crackers  in 
milk,  soft  eggs,  oysters  without  the  heel,  finely  minced  chicken,  etc. 

Coleman  has  shown  that,  by  the  free  use  of  milk-sugar  and  of 
cream,  loss  of  weight  in  typhoid  may  sometimes  be  prevented. 
The  cream  can  be  added  to  milk  or  to  other  foods.  Milk-sugar 
can  be  added  to  liquids,  in  the  proportion  of  \  oz.  in  4  oz.  (or  15 
c.c.  in  120  c.c.)  of  liquid.  Coleman's  diet,  if  used  indiscrimi- 
nately, may  perhaps  cause  death. 


71 


Departure  from  routine  diet  may  be  required  for  various 
reasons,  e.g. 

1.  Patient  too  weak  to  swallow  solid  food. 

2.  Vomiting. 

3.  Persistent  diarrhoea,  often  due  to  milk. 

4.  Severe  distension,  often  due  to  milk. 

Advantages  of  a  liberal  diet. 

1.  Weight  and  strength  are  better  maintained. 

2.  Toxemia  is  less. 

3.  Distension  is  uncommon. 

4.  Convalescence  is  shorter. 

5.  Patients  suffer  less. 

E.  Medication.  Hexamethylenamine  (p.  205)  should  be  pre- 
scribed by  routine  as  a  urinary  antiseptic.  It  may,  rarely, 
cause  hematuria  or  painful  micturition.  It  should  then  be 
omitted  for  a  few  days  and  resumed  in  smaller  dosage. 

Other  drugs  may  be  ordered  occasionally  for  special  symptoms 
as  required. 

Antipyretics  should  not  be  prescribed  to  reduce  fever,  but 
they  may  be  used  for  headache,  in  the  early  stages  of  typhoid. 
Being  depressants  they  are  dangerous  when  the  circulation  is 
impaired. 

F.  Observation. 

I.  Examine  the  patient  once  or  more  daily  during  the  febrile 
stage. 

Look  for: 

1.  Signs  of  circulatory  weakness. 

2.  Pulmonary  hypostasis. 

3.  Bed  sores. 

4.  Changes  in  the  condition  of  the  abdomen. 

(a)  Distension  of  abdomen. 

(b)  Spasm. 

(c)  Tenderness. 

(d)  Distension  of  bladder  from  retention. 


73 


II.  Keep  track  of: 

1.  Urinary  excretion. 

2.  Nourishment. 

3.  Account  for  changes  in  pulse  or  temperature.     They 

may  be  the  first  sign  of  hemorrhage  or  perforation. 

4.  Keep  sterile  salt-solution  ready  for  use  by  hypoder- 

moclysis  or  intravenously  in  case  of  need. 

III.  It  is  the  duty  of  the  physician  carefully  to  supervise 
treatment  during  the  period  when  hemorrhage  or  perforation 
may  occur,  and  he  himself  or  his  assistant  should  be  accessible 
at  times  when  emergencies  may  arise. 

G.  Convalescence.     In    convalescence   free    evacuation    of   the 
bowels  is  important. 
Massage  may  hasten  return  of  strength. 

H.  Nursing. 

The  nurse's  general  duties  are  to  do  her  utmost  to  spare  the 
patient  exertion,  discomfort  and  mental  unrest;  to  report  to  the 
physician  at  his  visit  all  changes  in  the  condition  of  the  patient; 
to  be  prepared  to  answer  questions  as  to  the  effect  of  treatment 
prescribed;  and  to  notify  the  physician  at  once  of  alarming  symp- 
toms or  signs  suggesting  severe  hemorrhage  or  perforation. 
She  should  know  the  possible  significance  of  sudden  changes  in 
pulse  rate  and  temperature  and  should  look  for  blood  in  every 
f cecal  dejection.  To  prevent  accident  she  should,  as  far  as  possi- 
ble, avoid  leaving  the  patient  alone  even  when  he  is  not  appar- 
ently delirious. 

The  following  complications  can  generally  be  prevented  by  an 
experienced  nurse :  — 

1.  Bed  sores.  5.  Boils. 

2.  Corneal  ulceration.  6.  Cracked  lips. 

3.  Middle-ear  infection.  7.  Tender  toes. 

4.  Parotitis.  8.  Hypostatic  congestion. 

1 .  To  prevent  bed  sores :  — 

(a)  Keep  sheets  smooth,  clean  and  dry. 
(6)  After  soiling,  clean  the  skin  promptly,  dry  it,  rub  in 
zinc  oxide  ointment,  and  powder  with  starch. 


75 


(c)  Change  the  patient's  position  occasionally. 

(d)  Do  not    allow   prolonged   pressure   on    bony   promi- 

nences. 

(e)  If  a  red  spot  appears  where  there  has  been  pressure 

keep  pressure  off  that  part  by  rings  or  pads  and 
paint  the  spot  with  picric  acid,  1  per  cent. 

2.  To  prevent  corneal  ulceration  keep  cornea  clean  by  bath- 
ing the  eyes  every  four  hours  with  a  2  per  cent  watery  solution 
of  boric  acid. 

3.  Boils  in  crops  are  generally  due  to  the  use  of  dirty  sponges. 
If  a  boil  appears  care  must  be  taken  to  avoid  spreading  the  in- 
fection. 

4.  Cracked  lips  can  be  prevented  by  the  use  of  cold  cream. 

5.  Middle-ear  infection  or  parotitis  may  result  from  improper 
care  of  the  mouth.  The  mouth  should  be  cleaned  and  the 
throat  sprayed  every  four  hours  with  a  non-irritating  antiseptic. 
Dobell's  solution,  or  "  alkaline  antiseptic  "  will  serve,  diluted,  if 
necessary,  with  one  or  two  parts  of  water  to  avoid  irritation  of 
the  mucous  membranes.  Excessive  dryness  of  the  tongue  from 
mouth  breathing  can  be  prevented  by  the  use  of  vaseline. 

6.  Hypostatic  congestion  of  the  bases  of  the  lungs  is  due  in 
part  to  protracted  lying  in  one  position.  It  can  be  combated, 
if  not  prevented,  by  rolling  the  patient  on  one  side  and  support- 
ing him  in  this  position  for  an  hour  or  more  by  means  of  a  pillow. 
The  patient  should  then  be  rolled  onto  the  other  side  for  another 
period  of  time,  and  these  manoeuvres  should  be  practiced  at 
least  once  daily. 

SYMPTOMATIC   TREATMENT   FOR  TYPHOID. 

Fever  and  Toxemia. 

Hydrotherapy  generally  acts  well. 
Benefits  expected  from  it  are: 

1.  Fall  of  temperature  of  from  1  to  2  degrees. 

2.  Fall  in  rate  with  increase  of  force  and  volume  of  the 
pulse. 

3.  Deeper  breathing  and  diminution  of  pulmonary  hypo- 
stasis. 

4.  Better  sleep. 

5.  Diminution  of  symptoms  of  toxemia. 


77 


Rules  for  use  of  baths: 

1.  Baths  should  be  ordered  for  definite  indications  only. 

2.  For  children  and  for  thin  and  feeble  patients,  baths  should 
be  warmer  and  shorter  than  for  the  robust  adult. 

3.  The  physician  should  supervise  the  first  bath  and  prescribe 
subsequent  baths  with  regard  to  the  effect  of  the  first  one. 

4.  If  the  pulse  gets  weaker  the  bath  should  be  stopped. 

5.  Much  cyanosis  or  shivering  after  the  bath  indicates  that 
it  was  too  cold,  or  too  long,  or  that  not  enough  friction  was  used. 

6.  Stimulants  are  seldom  required  before  or  after  a  bath  that 
is  suited  to  the  case  and  well  given. 

7.  Baths  must  be  modified  or  omitted  if  they  greatly  excite 
the  patient,  interfere  with  sleep,  or  cause  a  rise  of  temperature. 

Routine  bath  order.  For  temperature  *  of  103.5  degrees  rectal 
give  bath  every  four  hours  at  85°.  For  every  half  degree  of  tem- 
perature above  103.5°  lower  temperature  of  bath-water  5°. 

Methods  of  bathing: 

"  M.  G.  H.  Typhoid  Bath."  With  rubber  sheet,  supported 
at  edges  by  rolls  of  blanket  make  tub  in  bed  of  patient.  Dash 
water  over  him,  and  rub  vigorousl}'  in  turn,  with  the  hands,  the 
chest,  limbs,  and  back,  but  not  the  abdomen.  The  duration 
of  the  bath  should  be  20  minutes  or  less  if  so  ordered. 

Sponge  baths  often  act  well  and  are  preferred  in  many  cases. 
A  mixture  of  equal  parts  of  alcohol  and  2  per  cent  boric  acid 
solution  in  water  at  the  required  temperature  can  be  used  for 
bathing. 

CIRCULATORY  WEAKNESS.f 

I.  Cardiac  weakness  may  be  caused  by  various  conditions 
which  are  difficult  to  distinguish  from  one  another,  e.g., 

1.  Exhaustion  from  lack  of  nourishment. 

2.  Preexisting  cardiac  lesions. 

3.  Cloudy  swelling. 

4.  Fresh  endo-,  myo-  or  pericarditis. 

5.  Deranged  nervous  control. 


*  Temperatures  in  typhoid  are  best  taken  by  rectum  because  these  are  more 
reliable  than  mouth  temperatures.  The  rectal  temperature  averages  about 
1°  higher  than  the  mouth  temperature. 

t  Chap.  I,  p.  31,  33. 


79 


Symptoms  generally  develop  gradually  so  that  there  is  plenty 
of  time  to  prescribe. 

Stimulants  should  be  ordered  if  the  pulse  becomes  weak  or  ir- 
regular or  goes  above  120.  They  may  act  well  or  not  at  all,  and 
their  use  must  often  be  tentative. 

Digitalis,  caffeine  or  other  drugs  may  be  tried. 

Emaciated  or  septic  patients  taking  little  food  may  do  well  on 
alcohol.  It  seems  sometimes  to  act  as  a  food,  and  indirectly 
as  a  stimulant. 

II.  Vascular  relaxation  (p.  33)  is  suggested  when  the  pulse  is 
weak  in  proportion  to  the  heart  sounds.  The  condition  can 
generally  be  recognized  if  its  mode  of  development  has  been 
noticed  (p.  33). 

The  best  remedy  is  a  saline  infusion.  It  may  cause  a  rapid  fall 
in  the  pulse  rate  and  a  marked  improvement  in  the  pulse.  It 
may  be  necessary  to  repeat  the  infusion  after  some  hours  or  it 
may  not  be  required  again. 

DIARRHOEA. 

Severe  diarrhoeas  are  dangerous  and  must  be  checked. 

1.  Examine  stools  to  determine  if  they  contain  undigested 
food.  If  so,  omit  that  kind  of  food  or  reduce  the  amount. 
Curds  from  milk  may  be  found. 

2.  Tincture  of  opium  or  Paregoric  generally  acts  well. 

CONSTIPATION. 

Constipation  is  a  frequent  cause  of  fever  in  convalescence. 
Calomel  or  Fl.  Ex.  of  Cascara  Sagrada,  Castor-oil  or  "  Russian 
oil  "  (p.  217)  may  be  given  at  this  stage.  Neglect  of  the  bowels 
may  result  in  fcecal  impaction. 

DISTENSION. 

1.  If  stools  show  curds  reduce  or  omit  milk. 

2.  Turpentine  stupes  *  may  give  relief  and  can  be  used  p.r.n. 

3.  Rectal  tube  may  be  tried. 

VOMITING. 

Reduction  or  modification  of  diet  is  advisable  for  a  time  at 
least.  Swallowing  small  pieces  of  cracked  ice,  or  a  teaspoonful 
of  shaved  ice  with  brandy  may  relieve. 

*  See  textbook  on  nursing. 


81 


HEADACHE. 

If  not  relieved  by  an  ice-cap  placed  on  the  forehead,  phen- 
acetin  fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.),  with  caffeine  citrate 
1  gr.  (or  0.065  gm.),  or  some  other  analgesic  may  be  prescribed. 

COMPLICATIONS    OF   TYPHOID. 
I.     HEMORRHAGE   FROM   THE  BOWEL. 

Signs.  First  sign  of  small  hemorrhage  is  blood  in  the  stool. 
First  sign  of  large  hemorrhage  may  be  a  rapid  fall  in  tempera- 
ture and  a  rise  in  the  pulse  rate. 

Treatment.     1.  Omit  nourishment,  water,  and  baths. 

2.  Give  nothing  but  cracked  ice  by  mouth  for  24°. 

3.  Give  morphine  subcutaneously  —  repeat  dose  in  15  minutes 
or  half  an  hour  and  repeat  again  at  half-hour  intervals  until 
the  respiration  becomes  slower.  Do  not  let  the  respiration  fall 
below  10  per  minute.  When  it  has  reached  15  or  less  give  mor- 
phine in  small  dosage,  if  at  all,  lest  poisoning  result. 

The  object  of  using  morphine  is  to  stop  peristalsis  and  to  keep 
the  patient  quiet  until  the  hemorrhage  has  ceased. 

4.  If  the  patient  be  exsanguinated  raise  the  foot  of  the  bed  to 
prevent  death  from  syncope  but  do  not  stimulate  unless  there 
is  imminent  danger,  because  increase  of  blood-pressure  may 
prolong  the  hemorrhage. 

The  best  circulatory  stimulants  for  this  condition  are  a  saline 
infusion  or  a  direct  transfusion  of  blood. 

5.  For  small  hemorrhages  narcotization  with  morphine  may 
not  be  required. 

6.  Patients  who  are  very  weak  or  emaciated  should  be  fed 
in  spite  of  hemorrhage. 

II.     PERFORATION. 

Treatment.  —  Surgical.  Early  diagnosis  and  prompt  oper- 
ation are  essential  to  success.  When  the  condition  of  the  ab- 
domen has  been  watched  closely  before  the  appearance  of  the 
symptoms  of  perforation  the  diagnosis  will  be  easier.  Spon- 
taneous recovery  is  extremely  rare. 


83 

RHEUMATIC   FEVER. 

Note.  —  The  disease,  when  typical,  is  characterized  by  a 
migratory  articular  and  peri-articular  inflammation  with  pyrexia 
and  leucocytosis.  When  untreated  the  inflammation  generally 
lasts  about  six  weeks.  Relapses  are  common  and  endocarditis 
is  frequent.     Pericarditis  or  myocarditis  is  seen  occasionally. 

There  is  reason  to  believe  that  rheumatic  fever  is  a  form  of 
infectious  arthritis.  Perhaps  most  of  the  cases  are  due  to  a 
specific  organism. 

PRINCIPLES   OF  TREATMENT. 

1.  Rest  in  bed. 

2.  Relieve  pain. 

3.  Dilute  and  eliminate  toxins. 

4.  Prescribe  large  quantities  of  salicylate  and  of  alkali. 

5.  Prevent  recurrence. 

6.  Watch  for  cardiac  complications. 

METHODS. 

i.  Relieve  pain  by  protecting  the  joints  with  cotton  and 
bandages  or  by  splints.  For  psychic  effect  oil  of  gaultheria  may 
be  rubbed  on  the  skin  before  bandaging.  Fomentations  may  be 
useful  to  relieve  pain  and  a  hot  tub  bath  when  pain  and  fever 
permit  gives  much  relief.  If  the  pain  be  severe  and  not  con- 
trolled by  other  means  use  morphine  hypodermically  until  the 
salicylate  has  had  time  to  act. 

2.  Dilution  and  elimination  of  toxins  can  be  promoted  by  the 
free  administration  of  water.  Three  quarts  or  more  should  be 
ingested  in  twenty-four  hours  unless  the  heart  be  weak.  Cardiac 
complications  may  require  limitation  of  liquids. 

The  bowels  should  be  kept  clear.  Cathartics  may  be  pre- 
scribed as  needed. 

3.  Food  should  be  nutritious  and  as  abundant  as  can  be  di- 
gested because  wasting  is  often  rapid  and  anemia  may  develop. 

4.  Medication.  Sodium  salicylate  (p.  203)  or  some  other 
salicyl  compound  should  be  prescribed  in  large  dosage.  The 
quantity  should  be  proportional  to  the  degree  of  pain  and  acute- 
ness  of  the  inflammation.  For  severe  cases  10  grs.  (or  0.65  gm.) 
may  be  ordered  every  hour  until  the  patient  is  relieved  or  toxic. 


85 


To  avoid  irritation  of  the  stomach  every  dose  should  be  given 
with  a  full  glass  of  water.  Large  doses  of  sodium  bicarbonate 
seem  to  diminish  the  toxic  effects  of  salicylates.  Twenty  grains 
or  more  of  soda  may  be  ordered  with  every  dose  of  salicylate. 
Enough  soda  should  be  taken  to  render  the  urine  alkaline. 

Salicin  is  a  good  substitute  for  sodium  salicylate  and  seems  to 
cause  less  gastric  disturbance.  Aspirin,*  or  oil  of  gaultheria, 
may  be  tried. 

When  symptoms  have  been  relieved  the  dose  of  the  drug  can 
be  reduced.  It  should  be  continued  for  a  month  or  more  after 
the  patient  is  apparently  well. 

When  salicylates  act  well,  in  from  twenty-four  to  forty-eight 
hours,  a  fall  of  temperature  occurs,  and  with  it  there  comes 
diminution  of  joint  swelling  and  marked  relief  from  pain. 

The  common  symptoms  of  salicylate  poisonong  are  nausea  or 
vomiting,  tinnitus,  headache  and  occasionally  erythema  or  deliri- 
um. When  these  occur  the  drug  must  be  omitted  until  they 
subside.  It  may  then  be  resumed  in  smaller  dosage  or  in  differ- 
ent form. 

5.  Recurrence  of  arthritis  is  common  early  or  late. 

Early  recurrence  can  generally  be  avoided  by  keeping  the 
patient  in  bed  for  a  week  after  the  inflammation  has  entirely 
subsided  and  by  continuing  the  use  of  sodium  salicylate,  fr. 
30  to  40  grs.  (or  2  to  3  gm.)  daily,  for  one  month  or  more  after 
convalescence.     Exercise  should  be  resumed  gradually. 

Late  recurrence  and  future  cardiac  disease  can  often  be  pre- 
vented by  eliminating  all  foci  of  suppuration.  Inflammation 
of  the  tonsils  or  genital  tract,  sinus  infection  and  pyorrhoea 
alveolaris  should  be  looked  for.  Tonsillectomy  may  reveal 
deep  suppuration  not  demonstrable  externally.  Tonsillectomy  f 
should  be  insisted  on  if  the  tonsils  are  a  likely  source  for  future 
infection.  Pyorrhcea  can  be  benefited  by  rubbing  the  gums  daily 
with  a  solution  of  potassium  permanganate  and  by  rinsing  or 
sponging  the  mouth  frequently  with  hydrogen  peroxide  (p.  187). 

6.  Cardiac  complications  may  be  latent  or  severe.  Circu- 
latory weakness  may  require  limitation  of  liquids. 

The  patient  should  remain  flat  in  bed  for  weeks  or  months 
after  the  disappearance  of  all  signs  of  active  cardiac  infection, 

*  Incompatible  with  alkalis.     (N.N.R.) 

t  Dangerous  while  the  tonsils  are  acutely  inflamed. 


87 


.  and  should  avoid  exertion  of  all  kinds  for  several  months  there- 
after to  give  the  heart  ample  time  to  hypertrophy  or  to  adjust 
itself  to  the  changes. 

There  is  reason  to  believe  that  salicylates  taken  in  large  quan- 
tity tend  to  ward  off  endocarditis. 

For  further  information  on  endocarditis,  see  Chapter  I,  page 
21. 

ACUTE   INFECTIONS   MOST   COMMON   IN 
CHILDHOOD. 

By  Edwin  H.  Place,  M.D. 

SCARLET  FEVER. 

I.  Prophylaxis. 

A.  Immunity. 

1.  Natural.  Increases  much  after  8  years  of  age  and  marked 
after  21  years,  considerable  below  one  year  of  age  and  lowest 
from  2  to  6  years  of  age. 

2.  Active.  Claimed  by  Gabritschusky  by  means  of  vaccines' 
of  streptococci  obtained  from  scarlet  fever  cases.  Three  in- 
jections, at  intervals  of  4  days,  of  doses  of  from  one  to  ten  mil- 
lions may  be  used.     Value  very  doubtful. 

B.  Asepsis.     See  under  diphtheria  (p.  111). 

C.  Isolation  —  of  great  value  and  should  be  as  early  as  pos- 
sible. Finding  of  missed  cases  in  family  or  neighborhood  or 
school  often  possible  by  investigation  at  the  time  of  the  first 
recognized  case.  Isolation  should  be  carried  on  for  four  weeks 
and  until  there  are  no  abnormal  discharges. 

1.  Technique.  Technique  of  isolation  is  that  of  surgical  asep- 
sis reversed,  i.e.,  to  keep  infection  in  a  small  zone  instead  of  a 
small  area  free  from  infection.  Air  currents  play  no  practical 
part  in  spreading  the  disease. 

a  Avoid  infecting  clothing  or  utensils  from  careless  touch- 
ing of  patients  or  putting  infected  hand  or  things  into 
pockets,  etc.  Wear  gowns. 
b  Wash  hands  thoroughly  on  leaving  zone  of  infection. 
Do  not  handle  face  or  uninfected  objects  until  hands 
are  thoroughly  cleansed.     Be  careful  of  door  knobs. 


89 


c  Boil  dishes,  utensils,  etc.,  as  they  leave  patient.  Do  not 
put  down  infected  dishes,  etc.,  in  an  uninfected  zone. 

d  Boil  clothes  or  soak  them  in  5  per  cent  phenol  solution 
or  similar  germicidal  solution.  Be  careful  not  to  infect 
surroundings  in  removing  these  objects  from  the  in- 
fected zone. 

e  Use  care  to  prevent  discharges  from  nose,  throat,  ear, 
etc.,  from  being  spread  about  sick  room.  Use  soft 
piece  of  paper,  towel  or  cloth  and  deposit  at  once  in 
paper  bags  or  burn. 

/  Do  not  allow  infected  objects  as  thermometer,  pencils, 
stethoscope,  books,  money,  etc.,  to  be  taken  from 
infected  zone  without  proper  disinfection. 

g  Thorough  cleansing  of  patient  when  released  from  in- 
fected zone,  —  while  of  questionable  importance, —  still 
must  be  done.  The  mouth  should  be  thoroughly 
cleansed  and  antiseptic  sprays  may  be  used  in  the  nose, 
although  value  is  uncertain.  Patients  should  not  be 
released  until  all  signs  of  inflammation  of  mucous  mem- 
branes have  entirely  subsided. 

D.  Quarantine.  Exposed  persons  should  not  be  allowed  to  go 
to  new  places  or  come  in  contact  with  other  children  as  in  school 
or  social  assembly,  etc.,  until  2  weeks  after  the  last  exposure. 
Care  should  be  taken  to  see  that  they  have  not  a  mild  and  over- 
looked infection.  Closing  of  school  is  unnecessary  provided  care- 
ful study  of  the  children  is  made  to  eliminate  those  who  are  ill 
or  who  are  carriers. 

E.  Disinfection  —  of  doubtful  value  as  a  general  measure  of 
control.  Proper  cleanliness  and  asepsis  about  patient  obviates 
this  necessity.  In  well-lighted  and  aired  rooms,  objects  that 
might  have  been  infected  have  usually  ceased  to  be  a  source  of 
danger  by  the  time  the  patient  has  ceased  to  harbor  the  or- 
ganisms and  can  be  released.  Disinfection  can  be  done  by  ex- 
posure to  sun,  by  thorough  cleansing  and  washing  with  soap 
and  water  and  germicidal  solutions  such  as  phenol  or  corrosive 
sublimate  or  by  thorough  and  prolonged  exposure  to  formal- 
dehyde gas. 

II.  Treatment. 
The  great  dangers  of  scarlet  fever  are  sepsis,  cardiac  involve- 


91 


ment,  nephritis  and  toxaemia.      Of  these  sepsis   is  by  far  the 
greatest  factor  in  mortality. 

A.  Toxaemia,  treatment  of:  — 

1.  Serum  treatment.  Convalescent  patient's  blood  50  to  100 
cc.  should  be  used  intravenously  preferably.  Testing  for  syphilis 
and  bacterial  contamination  should  be  done  before  using  serum; 
this  treatment  of  limited  application  but  has  some  value, 

Antistreptococcus  serum  obtained  from  horses.  Moser's 
serum,  obtained  by  injecting  horses  with  many  strains  of  strep- 
tococci cultivated  from  scarlet  fever  patients,  may  be  used  in 
doses  of  at  least  200  cc.  It  is  of  little  value  in  some  cases  and 
often  disappointing. 

2.  Free  fluid  intake.  T|  litres  daily  according  to  age.  If 
patients  do  not  take  fluid  freely  it  may  be  given  by  rectum  or  sub- 
cutaneously  or  in  very  toxic  cases  intravenously  as  salt  solution. 

3.  Eliminative  treatment.  Mild  catharsis.  Daily  warm  bath, 
etc. 

4.  Rest  in  bed. 

B.  General  Sepsis,  treatment  of:  — 
1.  Prevention. 

a  Guarding  portals  of  entry. 

(1)  Local   cleansing   of  mouth,   gums,   teeth,   etc.,  with 

cotton  swab  applicator  2  or  3  times  daily.  Saline 
solution,  soda  bicarb,  solution,  borax  solution  or  a 
combination  of  these  with  10  or  20  per  cent  glycerine 
or  other  mild  cleansing  solution  may  be  used  such  as 
Dobell's. 

(2)  Protection  of  mucous  membranes  from  trauma,  etc. 

Alboline  and  similar  petroleum  oils  are  of  value 
following  cleansing  of  mouth,  especially  in  mouth 
breathers,  and  where  there  is  mucous  membrane  in- 
fecton.  Carious  teeth,  old  roots,  tartar  deposits, 
etc.,  should  be  seen  to. 

(3)  Antiseptics.     Phenol,    eucalyptus,   argyrol,   silver  ni- 

trate, iodine,  etc.,  are  of  doubtful  value.  Their  use 
may  cause  chemical  injuries  to  mucous  membrane. 
They  should  be  used  in  dilution  too  weak  to  cause 
irritation. 

(4)  Nasal  infection.     Nasal  infection  and  nasal  vault  in- 

fection as  well  as  accessory  sinus  disease  may  be  a 


93 


sources  of  danger  but  are  difficult  to  treat  effectually. 
Mechanical  cleansing  by  swabs  is  allowable.  Syring- 
ing is  liable  to  cause  injury,  or  spread  infection. 
Patient  may  clear  the  nose  by  blowing,  if  old  enough; 
application  of  ointment  and  medicated  oils  for  pro- 
tection and  mild  antiseptic  action  is  of  value. 

(5)  Burns,  wounds,  blisters,  etc.,  of  the  skin  should  be 

treated  aseptically  and  antiseptically  in  all  cases. 

(6)  Tonsilectomy.     Removal  of  tonsils  and  adenoids  as 

early  as  possible  in  the  acute  stage  of  infection 
has  been  suggested  and,  in  practice,  seems  to  be 
beneficial. 
b  General  Hygiene. 
2.  Treatment.     Same  as  prevention.     Rest  in  bed,  free  fluids, 
sunshine,  fresh  air,  outdoor  treatment.     Secure  sleep  and  com- 
fort by  alleviating  cause  of  discomfort  by  any  means  available. 
Sleep  and  rest  should  not  be  sacrificed  to  the  use  of  antiseptics, 
etc.     Supply  energy  by  easily  assimilated  foods.     Sugar  is  of 
great  value. 

C.  Local  Sepsis,  treatment  of:  — 

1.  Throat.      Antiseptics    of    questionable    value.      Cleanli- 

ness and  soothing  treatment  is  principle.  Swabbing 
local  lesions  carefully  with  one-half  strength  hydrogen 
peroxide,  20  per  cent  argyrol,  iodine  preparation,  5 
to  50  per  cent  silver  nitrate,  or  2  to  4  per  cent 
chromic  acid  solutions  selectively  used  may  be  of 
benefit.  Hot  irrigations  often  help.  Coughing 
and  struggling  when  irrigations  are  given  contraindi- 
cates  their  use. 

2.  Nose,     Cleansing    of   nose   by    the   patient  blowing   is 

better  and  safer  than  irrigations.     Sprays  are  of  little 
value  but  may  be  used. 
Instillations  of  15  per  cent  argyrol,  or  camphor,  gr.  v,  menthol, 
gr.  v,  and  iodine,  gr.  i,  in  alboline,  1  oz.  may  be  tried. 

Insufflations  of  calomel  powder  twice  daily  are  often  of  value. 
3.   Otitis  Media. 
a  Prevention. 

(l)  Avoid  nasal  irrigation,  palpation  of  nasal  vault  for  ad- 
enoids, coughing,  forcible  washing  of  throat,  Trendelenberg's 
position,  etc. 


95 


(2)  Prevent  obstruction  of  nose  from  acute  swelling  —  by  oily 
instillations  or  sprays  as  above.  Adrenalin  1  to  8000  in  oily 
preparations  (adrenalin  inhalant)  may  sometimes  help.  Ten 
drops  of  15  per  cent  argyrol  may  be  instilled  into  the  nostril 
and  allowed  to  run  down  into  the  fossa  of  Rosenmuller  by 
holding  head  to  that  side  while  in  the  supine  position  for  20 
minutes. 

Note.  —  Previous  abnormalities  of  nasal  vault,  such  as  ade- 
noids, large  turbinates,  etc.,  as  well  as  attempts  at  local  asepsis 
are  important  factors  in  causing  otitis. 

b  Treatment. 

(1)  Treatment  of  nose  and  nasal  pharynx  as  above. 

(2)  Free  drainage  by  cutting  drum  if  bulging.  Repeat  it  as 
often  as  necessary. 

(3)  Irrigations  ev.  2  to  4  hours  with  boric  acid  or  saline 
solution  at  100  to  110  degrees  Fahrenheit. 

(4)  The  dry  treatment  may  be  used  instead  of  irrigations 
especially  when  discharge  is  thin.  It  consists  of  frequent  spong- 
ing out  with  sterile  cotton  and  keeping  in  a  narrow  wick  to  the 
drum  but  not  closely  filling  the  canal.  To  this  may  be  added 
boric  powder  insufflations  or  instillations  of  5  per  cent  boric  acid 
in  15  per  cent  alcohol  solution.  Silver  salts  and  other  antisep- 
tics are  of  questionable  value. 

(5)  Watch  for  symptoms  of  mastoiditis. 

4.  Mastoiditis. 

a  Prevention.     Watch  and  promptly  treat  otitis  media. 
b  Treatment. 

(1)  Prompt  drainage  of  middle  ear  by  paracentesis.  Repeat 
as  often  as  necessary.  Copious  irrigations  every  2  hours  —  hot. 
Applications  of  ice  to  the  mastoid  process. 

(2)  Operation  is  indicated  if  tenderness  persists,  if  cedema  in- 
creases or  if  temperature  remains  up  for  more  than  3  days. 

5.  Cervical  Adenitis. 
a  Prevention. 

(1)  Throat  and  mouth  cleanliness,  attention  to  teeth,  gums, 
etc. 

(2)  Removal  of  tonsils  and  adenoids.  Even  in  an  acute  stage 
of  the  disease  removal  of  the  tonsils  has  given  highly  favorable 
results,  but  further  experience  is  desirable. 

(3)  Treatment  of  diseases  of  the  nose  and  accessory  sinuses. 


97 


6  Treatment. 

(1)  Ice  applications  the  first  few  days;  poultices  afterward. 
Resolution  without  pus  often  occurs  with  poultices. 

(2)  Treat  throat,  mouth  and  nose  as  needed. 

(3)  Chemical  applications  as  methyl  salicylate,  iodine  pet> 
rogen,  ointment  of  colloidal  silver  (Cred6)  are  of  very  doubtful 
value  but  may  be  used. 

(4)  Incision  if  suppuration  occurs.  Best  results  obtained  by 
not  incising  too  early,  allowing  pus  to  be  become  localized  and  the 
induration  to  subside.  Burrowing  of  pus  is  rare.  If  it  occurs 
incise  very  promptly.  Incision  should  be  as  short  as  possible 
and  in  lines  of  cleavage  of  the  skin  to  avoid  scar. 

6.  Pyaemia. 

Incisions  and  drainage  as  lesions  develop. 

7.  Arthritis. 

(a)  Simple.  (Scarlatinal  arthritis  and  periarthritis.)  Self- 
limited  in  a  few  days.  Rest.  Immobilization  by  cotton  batting 
bandages  or  splints.  Applications  of  methyl  salicylate  dressings, 
etc. 

(6)  Septic.  Incision  as  early  as  diagnosis  has  been  made. 
Thorough  and  prolonged  washing  out  of  cavity  and  sewing  up 
tight  has  given  the  best  result.  Incision  followed  by  rubber 
dam  drains  has  not  been  so  favorable.     Immobilization. 

8.  Phlebitis  (rare).  Elevation  for  circulation.  Local  heat 
such  as  poultices.     Citric  acid  internally  may  be  used. 

9.  Arterial  Thrombosis  (rare).  Elevation,  local  heat,  ampu- 
tation only  after  line  of  demarkation  has  formed. 

10.  Empyema.     Drainage  by  operation. 

11.  Peritonitis   (rare).     Operation  required. 

12.  Local  infections  can  then  be  benefited  by  autogenous 
vaccines. 

D.  Nephritis. 
I.  Prevention. 

a  Attempt  to  reduce  toxaemia  of  acute  stage.  See  under 
toxaemia. 

b  Kidney  rest. 

(1)  Rest  in  bed  for  at  least  three  weeks  in  all  cases. 

(2)  Avoid  excessive  loss  of  heat  and  all  chilling  of  skin. 

(3)  Free  fluid  intake  in  the  absence  of  oedema  probably  bene- 
fits the  kidney. 


99 


(4)  Diet.  Low  protein,  chiefly  carbohydrate  and  fat. 
Avoid  extractives,  nucleo-proteids  and  foods  rich  in  purin. 
Cream  and  milk,  one  to  two  pints,  cereals,  especially  wheat, 
rice,  baked  potatoes,  tapioca,  sugar,  sweet  fruits,  bread,  green 
vegetables,  except  asparagus.  In  the  acute  stage  patient  may 
refuse  everything  but  fluids.  Sugar  may  be  used  at  this  time 
freely. 

(5)  Daily  hot  bath. 

(6)  Salt  intake  may  be  reduced  but  value  is  uncertain.  Alkalis 
may  be  given. 

1.  Treatment.     See  Nephritis,  page  49. 

2.  Uraemia.     See  page  59. 

E.  Cardiac  complications. 

1.  Endocarditis. 
a  Prevention. 

(1)  Avoid  and  promptly  treat  local  infection  as  alveolar 

abscess,  otitis  media,  septic  joints,  diseased  tonsils, 
accessory  sinus  disease  and  other  focal  infections, 
which  may  be  responsible  for  infection. 

(2)  Prevent    exertion    during    the    period    likely    to    be 

attended  by  cardiac  complications . 

(3)  Reduce  Toxemia. 
b  Treatment. 

(1)  Rest  to  be  as  complete  as  possible,  prolonged  until 

lesion  has  entirely  healed  —  2  to  6  mos.  Cardiac 
stimulants  are  contraindicated  because  cardiac  in- 
sufficiency does  not  develop  early.  An  ice-bag, 
aconite,  or  bryonia  may  perhaps  give  the  heart 
relative  rest  by  quieting  its  action. 

(2)  Salicylates.     Danger  of  kidney  injury  must  be  kept 

in  mind. 

2.  Pericarditis.     The  same  as  endocarditis. 

Morphine  may  be  necessary  because  of  pain.  Posture  may 
need  to  be  upright  also  for  this  reason.  Fluid  may  require  as- 
piration.    Pus  will  require  operation  and  drainage. 

F.  Fever.  Usually  self -limited,  not  prolonged.  Alcohol  rubs, 
cold  sponges,  cold  baths,  may  be  used  for  a  stimulant  effect. 
Friction  of  the  skin  is  usually  advisable  while  using  cold  treat- 
ment. Friction  alone  using  cocoa  butter  may  also  reduce  tem- 
perature, stimulate  vaso-motors  and  add  to  comfort. 


101 

MEASLES. 
I.  Prophylaxis. 

A.  Immunity.     Practically  none. 

B.  Asepsis.  Particularly  difficult  in  general  life  because  of 
droplet  infection.  The  most  casual  contact  will  allow  the  disease 
to  be  contracted.  Avoid  the  region  of  persons  who  sneeze. 
Keep  hands  clean  and  avoid  touching  mouth  or  nose  with  infected 
hands  or  infected  objects. 

C.  Isolation  —  of  little  general  value  because  of  the  contagious- 
ness of  the  disease,  and  the  appearance  of  contagiousness 
usually  several  days  before  the  disease  is  recognized.  Isolation  to 
be  of  any  value  should  be  secured  early  in  the  catarrhal  stage, 
and  continued  until  the  acute  catarrhal  stage  has  subsided, 
that  is,  from  seven  to  fifteen  days. 

Technique.  Patient  must  be  isolated  so  that  droplet  infec- 
tion may  not  be  carried  to  others,  otherwise  technique  same  as 
for  scarlet  fever  except  of  much  less  importance. 

D.  Quarantine.  The  one  effective  means  of  control.  Patients 
exposed  should  be  kept  from  contact  with  non-immunes  until 
three  weeks  from  the  last  exposure.  The  disease  cannot  be 
stopped  in  schools  by  inspection  and  requires  closing  of  the 
schools  if  it  is  desired  to  check  the  epidemic.  Closing  of  the 
schools  to  be  of  value  requires  prevention  of  continued  contact 
of  the  families  of  a  community. 

E.  Disinfection  —  of  practically  no  general  value.  Measles 
contagion  dies  with  extreme  rapidity  and  probably  invariably 
within  24  hours  under  ordinary  conditions.  Surroundings  of 
patients  who  have  recovered  have  ceased  to  be  infected. 

II.  Treatment. 

The  chief  cause  of  death  is  secondary  infection  of  mucous 
membranes  of  which  pneumonia  is  of  greatest  importance. 
Treatment,  therefore,  should  be  directed  against  mucous  mem- 
brane infection,  especially  of  the  lungs. 

A.  Acute  toxaemia. 

1.  Free  fluid  intake. 

2.  Cathartics  must  be  used  carefully  to  avoid  causing  diarrhoea. 

3.  Stimulation. 

a  Tepid  baths  or  cool  sponging. 

b  Friction  to  skin,  as  cocoa  butter  rubs,  etc. 


103 


B.  Mucous  membrane  infections. 

1.  Bronchopneumonia. 

a  Prevention. 

(1)  General  resistance.     Fresh  air,  sunshine,  rest  in  bed, 

and   food   easy  to   digest   and  to    absorb  help  to 
maintain  resistance. 

(2)  Local  resistance.     Mouth  cleanliness,  prevention  of 

nasal  and  laryngeal  obstruction,  soothing  oily  sprays 
may  do  good. 

(3)  Avoidance  of  other  infections  as   colds,   diphtheria, 

etc. 
b  Treatment.     See  pneumonia,  page  121. 

2.  Acute  laryngitis. 

a  Expectorants  of  which  water  is  the  most  essential,  syrup 

ipecac,  syrup  hydriodic  acid,  etc. 
b  Steam    inhalations  with    compound  tincture   of  benzoin 

and  menthol,  followed  by  oily  sprays. 
c  Intubation  if  obstruction  occurs  and  requires  it. 
d  Antitoxin  in  all  cases  unless  diphtheria  has  been  excluded 

by  examination  of  the  larynx  and  taking  cultures  from 

the  larynx. 

3.  Tracheitis.     Same  as  laryngitis. 

4.  Otitis  Media.     See  scarlet  fever. 

5.  Rhinitis. 

a  Soothing  applications,  oily  sprays. 

6  Atropine,  camphor,  etc.,  as  in  rhinitis  tablets. 

6.  Stomatitis. 

a  Mouth  cleanliness. 

b  Hydrogen  peroxide  if  teeth  and  gums  are  foul  —  use  once 
or  twice  daily. 

c  Chromic  acid  solution,  2  to  4  per  cent:    apply  with  swab 
once  daily. 

d  Removal  of  carious  roots,  bad  teeth,  etc. 

e  Careful  avoidance  of  trauma  of  any  kind.     Mouth  clean- 
liness, mild  antiseptic  solution  with  cotton  swab  appli- 
cators. 
Iodine  preparations  and  silver  nitrate  may  have  value  in  cer- 
tain selected  conditions. 

7.  Noma. 

a  Prevention.      Careful   attention   to   mucous   membranes 


105 


of  the  mouth  prevents  stomatitis.  Avoid  trauma  by 
teeth  Q_r  manipulations.  Treat  all  ulcers  promptly 
with  peroxide  and  apply  chromic  acid  solution. 
b  Treatment.  Escharotic  to  destroy  completely  the  in- 
fected area;  the  actual  cautery  is  the  best,  with 
chloroform  anaesthesia. 

8.  Conjunctivitis. 

a  Boric  acid  solution  wash  three  times  daily. 
b  White  vaseline  for  lids, 
c  Avoid  injuring  cornea. 

9.  Entero-colitis. 

a  Prevention.  Avoid  overfeeding;  be  sure  that  milk  and 
other  food  is  free  from  contamination  or  is  pasteurized 
or  sterilized.  Avoid  unwise  catharsis.  Avoid  starva- 
tion. 

b  Treatment.  Force  fluid,  cereal  diet,  bismuth  in  drachm 
doses  every  four  hours.     Beta-naphthol  may  be  tried. 

PERTUSSIS. 
I.  Prophylaxis. 

A.  Immunity. 

1.  Natural.  Extremely  low  in  early  life,  becomes  greater  after 
five  years  and  considerable  in  adult  life. 

2.  Active  immunity  is  claimed  by  means  of  vaccine.  Value 
is  uncertain. 

B.  Asepsis.     Similar  to  that  of  measles,  p.  101. 

C.  Isolation.     Similar  to  that  of  measles,  p.  101. 

D.  Quarantine.     Similar  to  that  of  measles,  p.  101. 

E.  Disinfection.     Similar  to  that  of  measles,  p.  101. 

II.  Treatment. 

A.  Vaccines  still  remain  of  doubtful  value,  but  are  worthy  of 
trial.  Vaccines  containing  many  strains  of  the  Bordet-Gengou 
bacillus  should  be  used  —  dosage  of  from  100  million  to  a  1000 
million  may  be  used  at  intervals  of  from  two  to  five  days. 

B.  Hygienic. 

1.  Building  up  general  resistance.  Fresh  air  and  sunshine. 
Rest,  varying  with  the  amount  of  prostration  or  fever. 

2.  Diet.  Easily  digested  foods  such  as  cereals,  milk,  bread 
and  butter,  rice,  simple  puddings,  chicken,  scraped  beef,  zwiebach, 


107 


etc.  If  vomiting  occurs,  meals  should  be  frequent  and  small  in 
amount  and  given  if  possible  after  the  paroxysm.  If  a  meal  is 
vomited,  it  should  at  once  be  repeated.  High  protein  foods  are 
inadvisable  because  of  the  longer  stay  in  the  stomach  and  the 
danger  of  loss  from  vomiting. 

3.  Bitter  tonics,  iron,  etc.,  may  be  given.  Avoid  medicines 
which  might  upset  digestion. 

C  Local  resistance.  Avoid  dust,  irritant  gases,  etc.  Oily 
sprays  as  albolene  or  albolene  with  other  sedatives  or  antiseptics 
to  nose,  throat  and  larynx  may  be  used.  Free  water  intake  is 
essential.  Inhalations  of  steam  with  menthol  and  creosote  are 
sometimes  useful  to  stop  the  paroxysm,  but  must  not  be  used  at 
the  expense  of  general  hygienic  treatment. 

D.  Sedatives  should  be  used  only  when  demanded  for  severe 
cough  which  exhausts  the  patient  or  interferes  with  sleep  and 
nourishment.  Antipyrin  1  to  4  grs.  three  times  a  day,  or 
Quinine  Sulph.  2  to  5  grs.  may  be  tried,  or  Tincture  of  Bella- 
donna, beginning  with  1  to  3  min.  ev.  4  hours  and  increasing 
until  the  physiological  effect  appears  and  then  continuing  in 
slightly  smaller  doses.  Chloral  may  be  used  in  the  dose  of  2  to 
5  grs.  once  or  twice  a  day. 

E.  Paroxysms  of  cough. 

1.  Fresh  air  day  and  night  is,  probably,  the  most  efficient 
means  of  diminishing  cough. 

2.  Psychic  treatment  —  calm  the  fear  of  patient  by  psychic 
suggestion  and  avoid  psychic  upsets  and  loud  noises. 

3.  Avoid  all  irritants. 

4.  Pressure  on  the  epigastrium  or  the  use  of  tight  bands 
around  the  abdomen. 

5.  Spraying  the  larynx,  with  sedative  solution  such  as  menthol 
or  by  inhalations  of  steam  with  benzoin  followed  by  menthol, 
etc.,  are  of  limited  value. 

6.  Sedative  drugs:  see  above. 

F.  Complications. 

1.  Bronchopneumonia. 
A.  Prevention. 

(1)  Fresh  air  and  sunshine  throughout  the  disease. 

(2)  Rest. 

(3)  Keep  up  nutrition  by  wise  feeding. 

(4)  Avoid  fatigue  from  paroxysms. 


109 


(5)  Avoid  other  infections,  such  as  acute  colds,  irritants, 
such  as  dust,  etc. 

2.  Stomatitis.     See  Measles,  page  103. 

3.  Otitis  Media.     See  Scarlet  Fever,  page  93. 

4.  Cerebral  hemorrhages  may  be  guarded  against  by  attempt- 
ing to  control  severe  paroxysms  of  cough. 

5.  Vomiting.  Prevention  depends  on  control  of  cough.  The 
danger  is  malnutrition.  The  effects  can  be  minimized  by  fre- 
quent small  meals,  and  by  taking  food  promptly  after  vomiting. 

VARICELLA. 
I.  Prophylaxis. 

A.  Immunity.  Considerable  under  six  months  and  increased 
distinctly  after  five  years,  and  is  rather  marked  in  adult  life. 

B.  Asepsis.  Difficult  to  carry  on  in  practice,  the  disease  is  so 
contagious.     Principles  are  similar  to  scarlet  fever  and  diphtheria. 

C.  Isolation  —  should  be  insisted  on  as  early  as  possible  and 
continued  until  complete  healing  of  the  lesions  or  until  they  are 
entirely  dry. 

I.  Technique,  same  as  for  scarlet  fever  and  diphtheria,  p.  87. 

D.  Quarantine.     It  is  important  to  keep  exposed  persons  from, 
contact  with  others  for  three  weeks  after  the  last  exposure. 

E.  Disinfection.     See  Scarlet  Fever,  p.  89. 

II.  Treatment.  The  toxaemia  of  varicella  is  of  slight  im- 
portance. Nephritis  rarely  follows  the  disease.  The  chief  danger 
is  from  infection  of  the  skin  lesions  with  other  organisms  such  as 
the  streptococcus,  diphtheria  bacillus,  etc. 

A.  Toxaemia.  Cold  sponging,  ice  caps,  rest  in  bed,  force 
fluids,  during  the  acute  stage  of  fever. 

B.  Local  lesions.  Careful  asepsis  is  essential  from  the  be- 
ginning. Daily  baths  with  soap  and  water  preferably  by  shower, 
drying  the  skin  with  clean  towels  and  anointing  with  boric  acid, 
vaselin  or  camphorated  oil  are  of  value.  Underclothes,  night 
clothes  and  sheets  should  be  kept  scrupulously  clean  and  changed 
daily.  At  times  it  may  be  advisable  to  use  weak  chlorinated 
baths.  Chlorinated  soda  is  especially  beneficial  for  small  areas 
of  secondary  skin  infection  and  may  be  followed  by  application 
of  ammoniated  mercurial  ointment. 

C.  Mouth  lesions.  Occasionally  many  lesions  occur  in  the 
mouth  which  may  require  very  careful  asepsis  and  cleansing. 

D.  Corneal  or  conjunctival  lesions  may  occur.  Treatment  of 
these  lesions  should  be  very  prompt  and  active  to  avoid  blindness. 


Ill 

DIPHTHERIA. 
I.     Prophylaxis. 

A.  Immunity.  This  can  be  tested  by  Schick's  test,  zn  of 
the  minimum  lethal  dose  of  diphtheria  toxin  freshly  diluted  is 
injected  intracutaneously  into  arm.  A  positive  reaction  at  the 
end  of  48  hours  shows  a  red,  infiltrated  area  of  1  cm.  or  more 
in  size,  the  central  part  of  which  later  becomes  pigmented  and 
finally  desquamates.  The  whole  duration  of  the  lesion  is  one 
or  more  weeks.  Persons  having  a  positive  reaction  have  no 
antitoxic  immunity,  although  they  may  have  other  immunity. 
Those  showing  no  reaction  at  the  end  of  48  hours  are  immune. 
The  immunity  usually  persists  indefinitely.  False  reactions 
usually  occur  early  and  subside  quickly.  They  may  cause  an 
error  in  reading  results. 

1.  Passive.  1000  to  2000  units  of  antitoxin,  subcutaneously. 
For  immediate  need;  lasts  one  to  three  weeks  or  more. 

2.  Active.  Toxin  and  antitoxin  mixtures  are  used.  70  to 
85  per  cent  of  the  L  +  dose  of  toxin  mixed  with  one  unit  of  anti- 
toxin is  injected  at  intervals  of  one  week  for  three  doses.  An 
immunity  slowly  appears  that  lasts  months  or  years. 

3 .  Local.  Secure  good  local  conditions  of  mucous  membrane. 
Remove  bad  teeth  or  roots,  diseased  tonsils  and  adenoids,  etc. 
Treat  diseased  gums  and  mucuous  membranes  and  avoid  me- 
chanical or  chemical  injuries  to  the  mucous  membranes. 

B.  Asepsis. 

1.  Avoid  putting  fingers,  pencils,  pins,  etc.,  in  the  mouth  or 
to  the  nose. 

2.  Wash  the  hands  carefully  before  eating. 

3.  Do  not  use  common  drinking  cup  or  common  towel,  etc. 

4.  Avoid  kissing  on  lips. 

5.  Avoid  region  of  people  who  cough,  sneeze  or  spit. 

6.  Avoid  milk  handled  or  produced  under  poor  conditions, 
or  by  ill  persons,  and  avoid  public  dining  rooms  poorly  managed. 

C.  Isolation.  Isolation  is  of  great  value.  Prompt  recog- 
nition is  required  to  make  this  effective.  Missed  cases  also 
must  be  found  by  epidemological  studies,  and  culturing 
suspects.  Isolation  should  be  continued  until  virulent  diph- 
theria bacilli  have  been  absent  as  shown  by  cultures  for  at 
least  three  days. 

1.  Technique  of  isolation.     See  under  Scarlet  Fever,  p.  87. 


n; 


D.  Quarantine.  Quarantine  is  of  little  practical  value  as  cul- 
tures maybe  taken  in  exposed  persons,  and  if  found  to  be  negative, 
quarantine  need  not  be  continued.  Closing  of  schools  or  other 
places  of  assembly  is  unnecessary,  but  measures  should  be  taken 
to  discover  carriers  as  well  as  clinical  cases  among  those  who 
thus  come  together.  Schick's  test  is  of  great  value  in  finding 
those  who  are  susceptible  to  the  disease. 

II.  Treatment. 

The  chief  causes  of  death  in  diphtheria  are  the  result  of 
diphtheria  toxin  acting  on  the  nervous  centers  or  upon  the  heart 
or  peripheral  nerves  and  to  a  less  extent  of  mechanical  strangu- 
lation and  pneumonia,  as  in  the  laryngeal  cases.  The  essential, 
is,  therefore,  prompt  treatment  of  diphtheria  toxaemia  and  me- 
chanical obstruction  to  breathing. 

A.  For  Toxaemia. 

1.  Antitoxin. 

a  As  early  as  possible,  first  day  best. 

b  Dose,  varying  with  severity  of  disease  and  mode  of 
administration.  2000  for  very  mild  to  100,000  units 
or  more  for  very  severe  cases.     See  antitoxin,  page  191. 

2.  General  eliminative  measures.  See  principles  of  treatment, 
page  63. 

B.  For  obstruction  of  breathing. 

1.  Antitoxin  as  early  as  possible. 

2.  Intubation  for  obstruction  at  larynx. 

(a)  Indications.  Stridor,  use  of  accessory  muscles  of  res- 
piration, restlessness,  dyspnoea.  Relief  should  be 
secured  before  cyanosis  and  exhaustion  occur. 

3.  Tracheotomy. 

(a)  If  intubation  fails. 

(6)  For  obstruction  above  or  below  the  larynx. 

4.  Bronchoscopy. 

(a)  For  membranous  obstruction  low  down  in  trachea  or 
bronchi. 

C.  Local  treatment.     Of  slight  value  or  importance. 

1.  Cleansing  irrigations  for  the  throat.  Saline  solution,  boric 
acid  solution,  or  Dobell's  solution  may  be  used  copiously  for 
cleansing  and  soothing  mucous  membranes  and  should  be  used 


115 


as  warm  as  patient  can  tolerate  it.     Do  not  exhaust  the  patient 
by  excessive  attention. 

2.  Bacteriocidal  thereby  has  failed. 

3.  Soothing  applications  for  mechanical  protection  of  mu- 
cous membranes,  such  as  alboline  and  oily  sprays.  The  nose 
may  be  treated  in  this  way  or  by  instillations.  Irrigations 
should  not  be  used  in  the  nose. 

D.  Rest.  In  all  cases  in  which  toxaemia  is  marked  the 
patient  should  be  kept  in  bed  for  three  to  six  weeks,  because 
cardiac  or  nerve  complications  may  occur  as  late  as  this. 

E.  Hygiene.     Sunshine,  fresh  air,  freedom  from  dust,  etc. 

F.  Diet.  Large  amounts  of  fluid.  Balanced  diet  easily 
digestible  and  sufficient  for  energy  requirements.  No  special 
dietic  indications  except  digestibility  and  water  content. 

III.  Treatment  of  Complications. 

1.  Cardiac.  Occurs  chiefly  in  the  first  three  weeks  of  the  disease. 
a  Prevention.     Solely    by     early     antitoxin     in     sufficient 

amount. 
b  Treatment. 

(1)  Horizontal  position.     Do  not  allow  the  head  or  body 

to  be  raised. 

(2)  Nothing  by  mouth  if  nausea  or  vomiting  is  present. 

(3)  Nutrient  enemata  and   salt  solution   by  rectum  as 

required  by  thirst. 

(4)  Morphine  subcutaneously  in  small  doses  for  sedative 

effect. 

(5)  Stimulation  of  doubtful  value.     Caffeine  sodium  sali- 

cylate grains  one  to  five  ev.  4  hours,  subcutaneously. 
Note.  —  The  essential  of  treatment  is  to  secure  the  highest 
degree  of  rest  and  avoidance  of  strain  on  the  heart.  The 
disturbance  is  self-limited,  rarely  lasting  more  than  one  week. 
If  the  demand  on  the  cardiac  function  is  kept  to  a  minimum  for 
this  period,  recovery  may  occur. 

2.  Diphtheretic  Paralysis. 

(a)  Prevention.     Solely  by  early  administration    of    anti- 
toxin in  sufficient  amounts. 
(6)  Treatment. 

(1)  Improve  circulation  locally  by  massage,   electricity 
and  passive  motion. 


117 


(2)  Improve  general  condition.     Fresh  air,  sunshine,  food, 

iron  and  tonics. 

(3)  Antitoxin  is  of  no  value  after  the  paralysis  appears. 

3.  Otitis  Media.     See  under  Scarlet  Fever,  page  93. 

4.  Pneumonia.     See  under  Pneumonia,  page  121. 

5.  Chronic  "  tubes  "  ;  chronic  obstruction  of  larynx  after  in- 
tubation. 

a  Prevention. 

(1)  Avoid  trauma  in  operation. 

(2)  Correct  size  tubes  to  avoid  undue  pressure. 

(3)  Shortest  reasonable  duration  of  wearing  tube. 
b  Treatment. 

(1)  Tracheotomy  to  avoid  laryngeal  irritation  or  injury 

if  obstruction  persists  four  weeks  without  improve- 
ment. 

(2)  After  healing  of  larynx  mechanical  dilatation  by  means 

of  tubes  or  dilators. 

6.  Cervical  Adenitis.     See  under  Scarlet  Fever,  p.  95. 

7.  Serum  Disease. 

a  Urticaria.     Local  and  general  sedatives,  and  mild  cath- 
artics and  free  fluid  intake.     Adrenalin  1  to  1000  solu- 
tion, minims,  10  to  15  subcut.     Repeat  in  20  minutes 
if  necessary. 
b  Angio-neurotic  edema.    Treatment  unnecessary  and  in- 
effective, 
c  Eythema  multiforme.     No  treatment  effective. 
d  Enlargement  of  lymph-nodes.     Apply  ice. 
e  Arthralgia.    Immobilize,  gaultheria  dressings,  salicylates. 
/  Arthus'   phenomenon,  a  local    cellulitis  at    point  of    in- 
jection of  antitoxin.     Poultices. 
g  Vomiting.     Stop  everything  by  mouth  for  a  time. 
h  Anaphylactic  shock. 
(1)  Prevention. 

(a)  Skin  test.  Scratch  skin  and  apply  a  little  serum. 
Local  reaction  of  urticarial  type  in  2  to  15 
minutes  shows  susceptibility.  This  case  should 
be  given  serum  only  when  absolutely  essential 
and  under  special  precautions. 
(6)  If  sensitized  to  horse  serum  bovine  serum  may  be 
used,  but  sensitization  to  this  should  also  be  tested. 


119 


(c)  If  patient  is  sensitized,  desensitization  may  be  tried. 
(1)  Small  doses  starting  with  j^  cc.  to  tthttt  cc-> 

and  increase  the  dose  carefully  at  about  \  hour 
intervals. 

(d)  Paralyze  mechanism  of  shock,  i.e.,  bronchiole  spasm. 

(1)  Atropine  in  full  dose  subcutaneously,  1  half  hour 

before  serum. 

(2)  Adrenalin  in   full   dose    at    the    same    time   as 

serum. 
(2)  Treatment.     Usually  death  is  too  rapid  to  allow  of 
treatment  being  used. 
(a)  Atropine,  full  doses. 
(6)  Adrenalin,  full  doses. 

(c)  Oxygen. 

(d)  Heat. 

IV.  Carriers. 

1.  Remove  mucous  membrane  abnormalities,  if  possible. 
Enlarged  tonsils  and  adenoids,  foreign  bodies,  accessory  sinus 
disease,  carious  teeth,  etc. 

2.  Chemical  applications  have  been  of  very  doubtful  value  — 
silver  nitrate,  as  well  as  argyrol,  acetic  acid,  chromic  acid,  iodine, 
etc.,  have  been  used. 

3.  "Overriding,"  by  spraying  with  other  bacteria,  such  as 
the  staphylococcus  and  bacillus  bulgaricus  has  not  proved  of 
definite  value. 

4.  Powdered  kaolin  applications  at  short  intervals  has  not 
proved  its  value. 

5.  Vaccine  treatment  is  still  of  questionable  value. 


\ 

PULMONARY   INFECTIONS. 

LOBAR   PNEUMONIA. 

Notes.  —  An  acute  infectious  disease  of  multiple  etiology, 
most  commonly  caused  by  the  pneumococcus.  The  rate  of 
the  pulse  and  respiration  are  indices  of  toxemia. 

Mortality  commonly  due  to: 


1.  Toxemia 

less  often  to 

2.  Complications. 


(a)  Circulatory  disturbance. 

(b)  Asphyxia. 

(a)  Empyema. 

(b)  Pericarditis. 

(c)  Endocarditis. 


PRINCIPLES  OF  TREATMENT. 

1.  Secure  good  nursing  and  fresh  air. 

2.  Eliminate  and  dilute  toxins. 

3.  Watch  circulation. 

4.  Stimulate  promptly  when  required. 

5.  Prescribe  drugs  only  for  definite  reasons. 

6.  Take  precaution  to  prevent  accident. 

7.  Diet  suitable  to  case. 

8.  Recognize  complications  promptly. 

METHODS. 

1.  Eliminate  toxins  by  requiring  copious  ingestion  of  water, 
unless  the  heart  be  weak,  and  keep  the  bowels  clear.  Watch 
urinary  output  to  see  that  the  water  is  being  excreted. 

2.  Out-of-door  treatment  is  likely  to  benefit  robust  patients, 
but  the  old  and  feeble  are  likely  to  do  better  indoors.  Fresh 
air  is,  perhaps,  the  best  stimulant  in  pneumonia.  Sometimes  it 
diminishes  dyspnoea  and  promotes  comfort. 

3.  Note  the  outlines  and  sounds  of  the  heart  and  the  quality 
of  the  pulse  at  every  visit. 

121 


123 


4.  Stimulation  is  indicated  (a)  if  the  quality  of  the  pulse  be 
poor,  (6)  if  it  becomes  irregular  or  (c)  if  the  rate  go  above  120. 

Irregularity  early  in  the  illness  is  less  apt  to  herald  danger 
than  that  developing  late. 

5.  Morphine  is  indicated  to  relieve  pleuritic  pain  when  a  tight 
swathe  fails  to  do  so.  Sleep  is  very  important  to  conserve 
the  strength  of  the  patient  and  morphine  may  be  used  to  obtain 
it,  especially  in  the  early  stages  of  pneumonia. 

Morphine  is  contraindicated  whenever  bronchial  secretion  is 
profuse,  because  it  checks  expectoration,  and  if  morphine  is  to 
be  used  in  the  later  stages  caution  is  necessary. 

6.  Diet  should  consist  of  food  that  requires  no  chewing  and 
that  is  easily  swallowed;  i.e.,  liquids  and  soft  solids. 

The  amount  should  be  gauged  by  the  digestive  power  of  the 
individual,  but  the  usual  course  of  th.e  disease  is  so  short  that 
nutrition  is  seldom  important. 

7.  Avoid  renal  irritants  and  gas-producing  foods. 

Besides  the  complications  above-mentioned  look  out  for  a 
true  nephritis. 

8.  When  temperature  is  very  high  and  the  heart  doing  well, 
sponge  baths  may  be  used  to  reduce  the  fever. 

9.  Tympanites  may  require  treatment.  An  enema  of  1  oz. 
(or  30  c.c.)  of  glycerin  undiluted  generally  acts  well. 

10.  Dyspnoea  with  cyanosis  can  be  relieved  to  some  extent 
by  inhalation  of  oxygen  passed  through  absolute  alcohol. 

STIMULATION   OF   HEART. 

On  the  third  or  fourth  day,  10  m.  (or  0.6  c.c.)  of  Tr.  digitalis 
may  be  ordered  Lid.  It  may,  perhaps,  ward  off  sudden  dila- 
tation of  the  heart. 

For  irregularity  or  weakness  caffeine  sodio-salicylate  may  be 
used  subcutaneously,  and  at  the  same  time  digitalis  can  be 
given  by  mouth  for  subsequent  effect,  or  digipuratum  solution 
(p.  197)  can  be  injected  instead  of  caffeine. 

For  acute  cardiac  dilatation  the  following  remedies  may  be 
tried  according  to  circumstances: 

Subcutaneously : 

1.  Digipuratum-solution. 

2.  Camphor  in  oil:  3  grs.  (or  0.2  gm.).     It  should  be  specially 

prepared  for  subcut.  use. 


125 


3.  Caffeine  sodio-salicylate :  3  grs.  (or  0.2  gm.).     It  may  cause 

irritability  or  wakefulness. 
Intravenously  Digipuratum-solution  or  Strophanthin  (p.  197) 
may  be  given.     The  latter  is  dangerous. 
By  mouth: 

1,  Brandy,  fr.  \  to  1  oz.  (or  15  to  30  c.c.). 

2.  Aromatic  spirits  of  ammonia,  1  drach.  (or  6  c.c). 
Venesection  may  do  good  if  there  is  cyanosis  with  much 

engorgement  of  the  right  ventricle. 

Acute  pulmonary  edema  yields  occasionally  to  a  large  dose 
of  atropine  -fa  gr.  (or  0.001  gm.)  given  subcutaneously. 

Vascular  relaxation.  The  momentary  application  of  cold  in 
the  form  of  an  ice-bag  to  the  abdomen  may  do  good  by  causing 
reflex  vascular  contraction.  Salt  solution  subpectorally  or  in- 
travenously may  be  beneficial.  If  improvement  results  follow 
it  up  with  caffeine. 

DELIRIUM:  TREATMENT 

Active  delirium  may  be  ameliorated  by  morphine  (see  sec.  5, 
p.  123),  by  hypnotics,  or  sometimes  by  hyoscine  hydrobromate  * 
used  sub  cut.  Alcohol  internally  may  be  of  service  for  delirium 
with  exhaustion. 

Caution.  Delirium,  even  when  slight,  may  be  dangerous. 
When  the  nurse  leaves  the  room  even  for  a  moment  some  one 
should  take  her  place  lest  the  patient  jump  from  the  window. 
No  razor  or  weapon  of  any  kind  should  be  left  about. 

BRONCHO-PNEUMONIA. 

Treatment  is  essentially  the  same  as  for  lobar  pneumonia  ex- 
cept that  the  disease  generally  runs  a  milder,  but  longer,  course. 
Nutrition,  therefore,  is  more  important. 

Bronchitis  is  often  associated  with  broncho-pneumonia  and, 
when  this  is  the  case,  expectorants  may  be  of  service  during 
convalescence. 


Scopolamine  is  chemically  the  same  as  hyoscine.     (U.S.D.) 


127 

BRONCHITIS. 
ETIOLOGY. 

Acute  bronchitis  commonly  follows  infections  of  the  upper 
respiratory  tract  and  especially  infections  by  the  pneumococcus 
or  influenza  bacillus.  It  occurs  symptomatically  in  some  in- 
fectious diseases,  e.g.,  typhoid  and  measles. 

Chronic  bronchitis  is  often  associated,  in  old  or  middle-aged 
persons,  with  slight  cardiac  insufficiency  or  with  emphysema. 
Rarely,  gout  is  a  factor. 

DIAGNOSIS. 

Acute  or  chronic  bronchitis  may  be  simulated  by  tuberculosis 
and,  therefore,  sputum  examination  is  imperative.  Many  cases 
of  bronchiectasis  following  influenza  are  wrongly  diagnosed  as 
bronchitis  or  as  phthisis. 

ACUTE   BRONCHITIS:  TREATMENT. 

1 .  When  there  are  constitutional  symptoms  the  patient  should 
keep  warm  and  avoid  change  of  temperature  by  staying  indoors. 

2.  If  there  is  fever,  bed  may  be  advisable  or  necessary. 

3.  Bronchial  secretion  must  be  expectorated,  but  unproduc- 
tive cough  should  not  be  allowed  to  fatigue  the  patient  or  to 
prevent  sleep. 

If  the  cough  comes  from  laryngeal  irritation  (p.  147),  lozenges 
may  suffice  to  check  it;  if  from  the  larynx  or  trachea,  steam  in- 
halations (p.  147)  may  be  serviceable.  If  necessary  for  relief 
of  cough  codeine  sulphate  |  gr.  (or  0.016  gm.)  or  heroine  hydro- 
chloride *  iV  gr.  (or  0.005  gm.)  may  be  prescribed  for  use  in  the 
afternoon  or  at  night.  Morning  cough  is  generally  needed  to 
clear  the  lungs.     It  can  be  promoted  by  a  hot  drink. 

4.  Substernal  distress  or  pain,  see  tracheitis,  p.  147. 

5.  Expectorants  are  contraindicated  during  the  acute  stage  of 
bronchitis  because  they  irritate  the  inflamed  mucous  membrane. 
They  may  be  used  during  convalescence,  at  which  time  the 
expectoration  is  often  tenacious  and  difficult  to  raise. 

*  The  hydrochloride  of  the  diacetic  ester  of  morphine  (U.S.D.)  not  official. 
"  Heroin"  is  a  name  bearing  U.  S.  t  (N.N.R.). 


129 


6.  Several  weeks  are  generally  required  for  complete  recovery, 
but  when  the  patient  feels  well  he  may  be  allowed  to  resume 
his  occupation.  Smoking  and  cold  bathing  should  be  resumed 
cautiously  and  unnecessary  exposure  should  be  avoided  as  long 
as  expectoration  persists. 

CHRONIC   BRONCHITIS:  TREATMENT.* 

1.  Expectorants  are  generally  beneficial,  particularly  potas- 
sium iodide  in  the  dose  of  fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.),  t.i.d. 

2.  When  there  is  any  sign  of  cardiac  insufficiency,  appro- 
priate stimulants  are  indicated.  For  slight  insufficiency  the 
Compound  Squill  Pill  may  act  well  both  as  a  heart  stimulant  and 
as  an  expectorant.  The  usual  dose  is  from  6  to  9  pills  daily. 
They  should  be  freshly  prepared.  Systematic  cardiac  treat- 
ment may  be  required. 

3.  An  equable  and  warm  climate  may  promote  comfort, 
especially  for  elderly  persons. 

4.  If  the  presence  of  bronchiectasis  be  suspected  treat  the 
case  as  one  of  bronchiectasis. 

5.  Acute  exacerbations  of  chronic  bronchitis  may  be  treated 
much  as  is  acute  bronchitis,  but  severe  symptoms  generally 
indicate  that  some  form  of  pneumonia  has  developed,  and 
treatment  should  be  regulated  accordingly  (p.  121). 

6.  Codeine  sulphate  or  heroine  hydrochloride  should  not  be 
used  consecutively  over  long  periods  on  account  of  the  danger  of 
forming  a  habit. 

7.  The  bronchitis  of  overfed  patients  is  often  benefited  by  de- 
pletion.    Exclude  gout  as  a  factor. 

Note.  —  Much  improvement  may  be  hoped  for  but  cure  is 
hardly  to  be  expected  in  chronic  bronchitis. 

BRONCHIECTASIS. 

Note.  —  The  disease  is  chronic,  lasting  for  thirty  years,  more 
or  less.  The  patient  may  be  subjected  to  recurring  attacks  of 
broncho-pneumonia,  or  of  hemoptysis.  Many  patients  have 
emphysema    or    asthma. t     The    condition    is    often    diagnosed 

*  There  is  increasing  reason  to  believe  that  cases  of  supposed  chronic 
bronchitis,  in  the  great  majority  of  instances,  are  in  reality  pulmonary 
tuberculosis,  bronchiectasis,  or  slight  cardiac  insufficiency. 

t  Empyema,  abscess,  arthralgia,  or  pneumothorax  occur  in  rare  instances. 


131 


wrongly  as  bronchitis  or  tuberculosis.  Many  cases  are  traceable 
to  influenza.  The  sputum,  typically,  is  abundant,  purulent, 
greenish,  nummular,  can  be  raised  at  will  by  coughing,  and 
often  contains  abundant  influenza  bacilli  as  well  as  various  other 
organisms.  Repeated  examinations  may  be  necessary  to  demon- 
strate the  influenza  bacilli.  The  cavities  may  be  localized  in 
one  lobe  or  disseminated  throughout  both  lungs.  Nutrition  is 
generally  good.  As  the  physical  examination  may  show  only  a 
few  rales,  the  diagnosis  must  rest  on  the  history,  the  character, 
and  the  amount  of  the  sputum. 

TREATMENT. 

No  method  yet  devised  offers  hope  of  cure. 
Efforts  must  be  directed  to  relieving  the  patient  as  far  as 
possible  from  unpleasant  symptoms. 

1.  Teach  the  patient  to  drain  his  cavities  on  rising  in  the 
morning,  and,  if  necessary,  once  or  twice  later  in  the  day.  This 
can  be  facilitated  by  taking  a  drink  of  hot  water,  tea  or  coffee 
at  such  times.  Potassium  iodide  fr.  5  to  10  grs.  (or  0.3  to  0.65 
gm.)  or  other  expectorants  may  be  used  if  the  secretion  be  too 
viscid  to  come  up  readily. 

2.  Avoid  sedatives  because  they  check  free  expectoration. 
The  material  then  decomposes  in  the  cavities  and  gives  a  foul 
odor  to  the  breath  and  to  the  sputum. 

3.  In  extreme  instances  of  retained  secretion  the  condition 
with  its  dyspnoea  and  cyanosis  may  simulate  bronchial  asthma. 
A  differential  diagnosis  can  be  made  from  history  and  sputum. 
An  emetic  will  give  immediate  relief  by  clearing  the  lungs. 

4.  Most  of  these  patients  are  better  in  warm  weather.  A 
uniformly  mild  climate  may  relieve  but  cannot  cure. 

5.  Sputum  must  not  be  swallowed  because  diarrhoea  may 
result. 

6.  Foul-smelling  sputum  means  inefficient  drainage  of  cavities. 
The  odor  can  be  ameliorated  by  the  use  of  3  min.  (or  0.2  c.c.) 
of  Eucalyptol  on  a  lump  of  sugar  several  times  daily. 

7.  "When  the  disease  is  localized  in  one  lobe  of  the  lung  the 
chance  of  relief  by  surgical  means  may  be  considered. 


133 


PULMONARY  TUBERCULOSIS. 

By  John  Hawes,  2nd,  M.D. 

Synonyms. —  Consumption,  Phthisis,  Tuberculosis  of  the  lungs. 

Etiology.  The  tubercle  bacillus,  discovered  by  Robert  Koch 
in  1882.  Among  predisposing  factors  may  be  mentioned  an 
inherited  weakened  constitution  or  predisposition  to  the  disease; 
overwork,  or  bad  conditions  of  work,  such  as  the  dangerous 
trades;  poverty  and  poor  living  conditions;  bad  habits  —  al- 
cohol, etc;  certain  acute  diseases,  such  as  measles  and  whooping 
cough,  etc.;  or  in  fact,  anything  which  may  lower  the  resistance 
of  the  body  to  infection. 

COURSE  OF  THE  DISEASE. 

Pulmonary  tuberculosis  is  a  chronic  disease,  usually  lasting 
from  two  to  seven  years.  In  certain  acute  cases,  where  there  is 
either  an  overwhelming  amount  of  infection  or  a  great  lack  of 
resistance,  it  may  run  a  rapid  course,  ending  fatally  in  a  few 
months,  or  even  weeks.  In  such  cases,  toward  the  end  at  least, 
the  disease  is  not  confined  to  the  lungs  but  takes  the  form  of  a 
general  septicaemia.  Likewise,  in  certain  chronic  cases  it  may 
last  in  semi-active  form  for  fifteen  or  twenty  years  or  more. 
These  are  the  exceptions,  however.  The  usual  type  of  the  dis- 
ease, as  above  mentioned,  runs  a  course  of  from  two  to  seven 
years,  with  intermissions  of  long  or  short  duration  during  which 
time  the  disease  is  in  a  condition  of  arrest,  or  semi-arrest.  The 
object  of  treatment  is  to  make  these  periods  of  arrest  as  permanent 
as  possible. 

COMPLICATIONS  AND   SEQUELAE. 

1.  Tuberculosis  elsewhere  in  the  body,  especially  the  throat 
and  genito-urinary  tract. 

2.  Hemorrhage. 

3.  Cardiac  Weakness,  due  to  the  toxins  generated  by  the 
tubercle  bacillus. 

DIAGNOSIS. 

Do  not  wait  for  extensive  signs  in  the  lungs,  nor  for  a  positive 
sputum  before  making  the  diagnosis  and  instituting  treatment. 
Pay  special  attention  to  constitutional  signs  and  symptoms,  such 
as  evening  fever  and  rapid  pulse,  subnormal  temperature  and 
rapid  pulse,  loss  of  weight,  strength  and  energy,  etc.     Remember 


135 


that  in  most  instances  a  hemorrhage  from  the  mouth  means 
pulmonary  tuberculosis  and  also  that  most  pleurisies,  especially 
wet  pleurisies,  are  tuberculous.  Depend  more  on  the  thermom- 
eter and  common  sense  than  on  the  stethoscope  and  remember 
that  "absence  of  proof  is  not  proof  of  absence." 

PROPHYLAXIS. 

1.  Destruction  of  all  sputum.  See  that  the  patient  uses 
sputum  cups,  flasks,  or  cloth  or  paper  napkins  which  can  be 
burned,  according  to  the  amount  of  sputum. 

2.  See  that  the  patient  is  trained  to  place  his  hand  or  handker- 
chief in  front  of  his  mouth  on  coughing  or  sneezing. 

3.  Separate  the  children  to  as  great  an  extent  as  possible  from 
all  sources  of  infection,  whether  adults  or  other  children. 

4.  Mechanical  cleanliness  —  soap,  water,  scrubbing,  repaint- 
ing and  papering  is  the  best  means  of  treating  the  rooms  or 
premises  in  which  a  consumptive  has  lived,  in  order  to  make 
them  safe. 

5.  Observance  of  the  ordinary  rules  of  hygiene  and  right 
living,  as  to  work,  sleep,  play,  food  and  drink,  is  the  best  plan  for 
the  average  person  who  wishes  to  avoid  this  disease. 

TREATMENT  IN   GENERAL. 

Treatment  should  be  active  and  aggressive.  It  should  begin 
as  soon  as  the  physician  has  made  the  diagnosis;  in  certain  cases, 
this  may  be  before  he  has  seen  fit  to  tell  the  patient  definitely 
that  he  has  consumption.  In  the  vast  majority  of  instances, 
it  is  far  better  to  talk  frankly  and  plainly  to  the  patient.  If  the 
diagnosis  is  certain,  tell  the  patient;  if  you  are  in  doubt,  and 
merely  suspect  that  tuberculosis  is  the  cause  of  the  symptoms, 
explain  the  situation  frankly  and  clearly  to  the  patient  and  to 
his  relatives  and  friends.  In  no  other  way  can  cooperation  be 
secured. 

Methods  of  treatment  include  the  following: 

1.  Sanatorium  treatment. 

2.  Home  treatment. 

3.  Climatic  treatment. 

4.  Tuberculin. 

5.  Heliotherapy,  or  sunlight  treatment. 

6.  Drugs. 


137 


SANATORIUM   TREATMENT. 

Every  consumptive,  at  some  time  or  other  during  the  period 
in  which  he  is  trying  to  regain  his  health,  should  spend  some  time 
at  a  sanatorium.  The  length  of  time  necessary  to  spend  in  this 
way  may  be  short  or  long,  according  to  the  intelligence  and 
finances  of  the  patient  and  the  nature  of  his  disease.  In  select- 
ing a  sanatorium,  the  physician  should  consider  the  following 
points: 

(a)  Cost  per  week. 

(6)  Accessibility. 

(c)  Climate  and  altitude. 

(d)  Temperament  and  disposition  of  the  patient. 

(e)  Length  of  time  patient  expects  to  remain  at  the  sanatorium. 


HOME  TREATMENT. 

This  is  usually  necessary  before  and  after  the  patient  has 
been  at  a  sanatorium  or  some  similar  institution.  The  essen- 
tials of  successful  home  treatment  are: 

1.  Adequate  and  detailed  supervision  of  the  patient  by  phy- 
sician and  nurse. 

2.  Close  cooperation  between  patient  and  physician. 

3.  Provision  for  outdoor  sleeping. 

4.  Prolonged  rest. 

5.  Finances  sufficient  to  insure  proper  food  and  nursing. 


CLIMATIC  TREATMENT. 

Before  sending  a  patient  a  considerable  distance,  in  order  to 
give  him  the  benefit  of  a  certain  climate,  the  physician  should 
consider  the  following  points: 

1.  The  cost  of  transportation  and  the  cost  of  board  after  ar- 
rival. 

2.  Will  the  patient  be  happy  so  far  from  home? 

3.  Has  the  patient  funds  enough  to  remain  at  least  one  year? 

4.  See  that  the  patient  is  placed  immediately  under  high-grade 
medical  advice. 

5.  In  case  the  patient  has  had  hemorrhages,  will  it  be  safe  for 
him  to  go  on  account  of  the  altitude? 


139 


6.  Do  not  send  patients  far  away  from  friends,  no  matter  how 
favorable  the  climate,  if  they  are  in  the  advanced  or  progressive 
stages  of  the  disease. 

7.  Remember  that  even  if  the  patient  gets  an  apparent  arrest 
of  his  disease  in  a  certain  favorable  climate,  it  may  be  impossible 
for  him  to  live  in  any  other  climate,  or  to  return  home  to  live 
with  his  relatives  and  friends  with  safety. 

TUBERCULIN  TREATMENT. 

The  general  practitioner  should  not  undertake  this  form  of 
treatment. 

HELIOTHERAPY  OR  SUNLIGHT  TREATMENT. 

This  may  be  tried  in  certain  cases  of  pulmonary  disease  under 
most  careful  supervision.  The  physician  should  not  try  it, 
however,  until  he  has  made  a  careful  study  of  the  subject,  and 
familiarized  himself  with  all  details. 

TREATMENT   BY   DRUGS. 

Drugs,  in  the  treatment  of  pulmonary  tuberculosis,  are  used 
merely  to  treat  symptoms  —  never  the  disease  itself.  The  in- 
testinal  tract  must  be  kept  clear,  hence,  saline  or  vegetable  laxa- 
tives are  often  needed.  Diarrhoea  must  be  checked.  Exces- 
sive, unproductive  and  irritating  cough  must  occasionally  be 
allayed.  In  certain  instances,  a  mild  tonic  to  stimulate  appetite 
is  indicated.  Aside  from  these,  no  drugs  are  needed  in  the 
treatment  of  pulmonary  tuberculosis. 


141 

ACUTE      INFLAMMATION      OF      THE      UPPER 
RESPIRATORY   TRACT. 

Etiology:  infectious  in  most  instances.  The  pneumococcus, 
staphylococcus,  influenza  bacillus,  diphtheria  bacillus,  micro- 
coccus catarrhalis  or  other  bacteria  may  be  causative.  Among 
predisposing  factors  lowered  physical  resistance  and  exposure 
to  cold  are  important. 

Course  of  Disease.  Inflammation  generally  begins  in  the 
nasopharynx  (pharyngitis).  It  usually  extends  within  a  few  days 
to  the  nasal  mucous  membrane  (coryza)  and  often  to  the  tonsils 
(tonsillitis)  or  lar3rnx  (laryngitis).  The  severity  and  extent  of 
the  inflammation  depends  chiefly  on  the  kind  and  virulence  of 
the  infecting  organism  and  on  the  resistance  of  the  patient. 

Complications  and  Sequelae. 

1.  Bronchitis.  8.  Bronchiectasis. 

2.  Otitis  media.  9.  Septicaemia. 

3.  Peritonsillar  abscess.  10.  Meningitis. 

4.  Lobar    or    broncho-  11.  Peritonitis. 

pneumonia.  12.  Inflammation      of      the 

5.  Arthritis.  antrum,  frontal,  eth- 

6.  Endocarditis.  moidal  or  sphenoidal 

7.  Glomerulo-nephritis.  sinuses. 

Diagnosis.  Exclude  whooping-cough,  scarlet  fever,  measles 
and  diphtheria.  The  diagnosis  of  diphtheria,  in  some  cases, 
can  be  made  by  culture  only.  Therefore  the  safest  plan  is  to 
take  a  culture  in  every  case  of  inflammation  of  the  throat  and, 
if  the  report  be  negative  but  the  signs  suggestive  of  diphtheria 
to  take  another  culture. 

PROPHYLAXIS. 

1.  If  there  is  a  reasonable  probability  that  the  symptoms  are 
due  to  diphtheria  or  to  one  of  the  exanthemata  isolate  the  patient 
provisionally. 

2.  If  the  clinical  evidence  points  to  diphtheria  administer 
antitoxin  (p.  191)  to  the  patient  without  waiting  for  the  report 
on  the  culture;  or  even  if  the  first  culture  be  negative. 


143 


Prophylactic  inoculation  of  all  persons  exposed  to  diphtheria 
should  be  insisted  on. 

3.  Patients  having  infections  of  the  respiratory  tracts  should 
cover  the  mouth  on  coughing  or  sneezing. 

4.  Good  ventilation  of  rooms  occupied  by  the  patient  reduces 
risk  of  contagion. 

TREATMENT  APPLICABLE  IN   GENERAL. 

1.  Keep  the  patient  in  a  warm,  but  well-ventilated  room  at 
a  uniform  temperature. 

2.  Promote  rest  and  sleep,  using  sedatives  or  hypnotics  when 
needed. 

3.  Move  bowels,  at  outset,  by  enema  or  cathartic  unless  they 
have  been  acting  freely. 

4.  Allay  unproductive  or  irritating  cough  by  lozenge  or  sedative. 

5.  Avoid  local  irritation  by  tobacco  or  concentrated  liquor. 

6.  Cleanse  mucous  membrane  frequently,  and  soothe  in- 
flammation by  means  of  a  non-irritating  gargle.  Warm  water, 
with  or  without  salt  or  sodium  bicarbonate  in  it,  or  Liquor  anti- 
septicus  alkalinus  (N.F.)  may  be  used  diluted  with  3  parts  of 
warm  water. 

7.  Antipyretics,  e.g.,  phenacetin  fr.  5  to  10  grs.  (or  0.3  to  0.65 
gm.),  with  caffeine  citrate  1  gr.  (or  0.065  gm.),  or  salicyl  prep- 
arations (p.  203),  may  alleviate  discomfort  especially  if  there 
be  fever,  malaise  or  pain. 

8.  Food  should  be  readily  digestible  and  easy  to  swallow. 

Abortive  Treatment.  This  can  be  effective  in  the  early  stages 
only,  and  seldom  even  then.  The  following  measures  may  be 
tried. 

1.  Cleansing,  non-irritating  gargle. 

2.  Hot  bath  before  retiring,  or 

3.  Hot  drink  on  retiring  to  produce  sweating. 

4.  Early  to  bed,  and  hypnotic  unless  sleep  comes  quickly. 

5.  Catharsis  by  calomel  or  saline. 

6.  The  patient  should  dress  in  a  warm  room  and  avoid  cold 
bathing  on  the  following  morning. 


145 

METHODS    OF    TREATMENT. 
ACUTE   PHARYNGITIS. 

1.  Cleansing  gargle  every  four  hours. 

2.  Oil  spray  *  after  gargle  to  protect  and  soothe  mucous  mem- 
brane. 

3.  Check  cough  with  lozenges  (p.  147)  when  possible.  Other- 
wise use  codeine  or  heroin. 

CORYZA. 

Keep  the  nose  as  free  as  possible  from  secretion. 

Irrigation  of  the  nose  with  an  alkaline  solution  often  gives 
much  relief,  but  some  physicians  believe  that  this  practice 
may  lead  to  inflammation  of  the  frontal  sinus  or  middle  ear. 
An  oil  spray  *  may  be  used  to  free  the  nasal  passages. 

If  the  secretion  be  profuse  and  watery,  its  quantity  can  be 
diminished  by  using  ^^  gr.  (or  0.00032  gm.)  of  atropine  sul- 
phate and  repeating  it  in  fr.  4  to  6  hours  s.o.s.  Atropine  is 
contraindicated  when  secretion  is  viscid  or  tenacious.  Excessive 
dosage  causes  dryness  of  the  throat,  increases  discomfort,  and 
may  cause  severe  poisoning. 

Atropine  can  be  used  in  the  form  of  Tr.  of  belladonna  leaves; 
dose  from  10  to  30  min.  (or  0.6  to  2  c.c). 

ACUTE   TONSILLITIS. 

1.  Take  a  culture. 

2.  Whereas  the  constitutional  symptoms  are  apt  to  be  severe 
it  is  generally  advisable  to  keep  the  patient  in  bed. 

3.  Prescribe  cleansing  gargle  to  be  used  every  four  hours. 
The  tonsils  may  be  painted  daily  with  argyrol,f  fr.  10  to  20  per 
cent  in  watery  solution. 

4.  An  oil-spray,*  used  after  gargling,  may  give  some  relief. 

5.  An  ice-bag  collar  may  help  much  to  relieve  pain  in  the 
throat. 

6.  The  diet  must  be  easy  to  swallow.  Cold  drinks  may  be 
grateful. 

*  Petrolatum  liquidum  will  serve.  Menthol  5  grs.  (or  0.3  gm.)  or  Eucalyptol 
5  min.  (or  0.3  c.c.)  or  both  can  be  added  per  oz.  (or  30  c.c.)  of  liquid  petrolatum. 
The  De  Vilbiss  atomizer  ia  good. 

t    U.  S.  t. 


147 


7.  Occasional  doses  of  phenacetin  or  of  a  salicyl  preparation 
(p.  203)  may  be  beneficial  for  fever,  malaise  or  pain. 

8.  Opiates  or  hypnotics  are  indicated  sometimes. 

9.  Salicylate  (p.  203)  in  large  doses  acts  well  in  some  cases 
of  tonsillitis  having  slight  articular  symptoms  due  probably 
to  streptococcus  infection. 

10.  Note  at  first  visit  the  size,  position  and  sounds  of  the  heart, 
and  the  presence  or  absence  of  murmurs.  Watch  for  any  change 
and  before  discharging  the  patient,  determine  whether  the 
heart  or  the  kidneys  have  suffered. 

ACUTE  LARYNGITIS. 

1.  Scarification,  intubation  or  even  tracheotomy  may  be  re- 
quired for  edema. 

2.  Steam,  plain  or  medicated,  ordinarily  gives  relief.  It 
should  be  used  every  few  hours  or  as  desired.  The  steam  can 
be  inhaled  from  the  mouth  or  from  a  pitcher  containing  boiling 
water.  To  the  water  may  be  added  1  drach.  (or  4  c.c.)  of 
compound  tincture  of  benzoin.  A  steam  atomizer  which  can 
be  used  to  spray  oil  and  steam  together  is  still  better.  For  very 
sensitive  throats  the  steam  and  oil  may  act  better  without  other 
ingredients,  but  Menthol  5  grs.  (or  0.3  gm.),  or  Eucalyptol  5 
min.  (or  0.3  c.c),  or  both  can  be  added  per  oz.  (or  30  c.c.)  of 
Liquid  petrolatum. 

Excessive  dryness  of  the  air  of  the  room  is  harmful.  It  can 
be  mitigated  by  allowing  steam  to  escape  constantly  from  kettle 
or  chafing  dish. 

3.  Cough  must  be  checked  and  talking  minimized. 

4.  Smoking  is  especially  harmful  as  a  rule. 

ACUTE   TRACHEITIS. 

Treatment  as  for  laryngitis  may  suffice. 

A  flaxseed  or  mustard  poultice  *  for  the  upper  chest  or  steam 
inhalation  may  help  to  relieve  substernal  distress.  Mustard 
should  be  avoided  if  resulting  pigmentation  would  contraindicate 
its  use.  "  Gomenol  jujubes  "  f  taken  every  3  to  6  hours  may 
relieve. 


*  See  textbook  on  nursing. 

t  A  preparation  of  Oleum  cajuputi  (U.S.). 


CHAPTER    IV. 


GASTRIC   AND   DUODENAL   ULCER. 
INDICATIONS   FOR   MEDICAL   TREATMENT. 

1.  Recent  ulcers. 

2.  Chronic  ulcers  with  mild  symptoms. 

3.  Chronic  ulcers  which  have  not  had  satisfactory  medical 
treatment. 

4.  Ulcers  for  which  surgical  treatment  is  too  dangerous  or  has 
been  refused. 

5.  As  a  preparation  for  operation. 

The  prognosis  under  medical  treatment  is  better  the  more 
recent  the  ulcer. 

PRINCIPLES   OF   TREATMENT. 

The  principles  and  methods  are  essentially  the  same  whether 
the  ulcer  is  in  the  stomach  or  in  the  duodenum. 

1.  Prolonged  rest  for  the  patient  and  for  the  digestive  tract. 

2.  Avoidance  of  food  mechanically  or  chemically  irritating. 

3.  Reduction  of  gastric  secretion  to  the  minimum. 

4.  Good  care  of  teeth. 

METHODS. 

A.  Rest  for  a  month  or  more  is  essential. 

B.  Diet  should  consist  chiefly  of  soft  carbohydrates,  fats,  milkr 
and  eggs.     Feeding  should  be  frequent. 

Treatment  may  be  begun  by  starvation  for  several  days, 
if  the  stomach  be  very  irritable.  Nutritive  enemata  are  seldom, 
if  ever,  of  much  value  because  they  are  not  well  absorbed. 
During  the  period  of  starvation  three  pints  of  salt  solution  should 
be  given  daily  by  rectum.  Cracked  ice  may  be  sucked  to  allay 
thirst. 

Begin  feeding  with  small  quantities  of  milk  (see  Vomiting, 
p.  161).     Later,  bread,  or  crackers  and  milk,  milk  toast,  strained 

149 


151 


cereals  with  cream  and  sugar,  rice,  custard,  blancmange,  junket, 
simple  ice  cream,  mashed  or  baked  potato  with  cream  or  butter, 
eggnog,  raw  or  soft  boiled  or  dropped  egg,  purees,  soft  fruits, 
etc.,  can  be  added  later  to  the  dietary  until  the  patient  is 
taking  ample  nourishment. 

The  nutritive  value  of  liquids  can  be  much  increased  by  add- 
ing to  them  sugar  of  milk,  fr.  \  to  1  oz.  in  4  oz.  (or  fr.  15  to  30 
gm.  in  120  c.c.)  of  liquid.  Cream  may  be  added  to  milk,  and 
butter  should  be  used  freely. 

Irritating  foods,  e.g.,  coarse  vegetables,  condiments,  acids, 
and  particularly  alcohol  must  be  avoided. 

Hot  drinks  and  meat  broths,  as  a  rule,  should  not  be  taken. 

Proteid  foods,  in  the  opinion  of  the  writer,  are  to  be  avoided, 
as  a  rule,  except  in  the  form  of  milk  or  eggs. 

C.  Modification  of  diet  is  required  for  patients  that  are 
emaciated,  or  feeble  and  anemic.  For  them  starvation  may  be 
harmful,  and  it  may  be  wise  to  begin  feeding  by  mouth  soon 
after  the  hemorrhage  has  stopped,  and  quickly  to  increase  the 
amount  of  food  ingested  in  order  to  accelerate  healing  by  im- 
proved nutrition.  The  experience  of  the  patient  with  the 
peculiarities  of  his  digestion  requires  consideration. 

In  marked  contrast  to  those  expressed  above  are  the  views 
held  by  some  physicians  who  advocate  a  diet  consisting  chiefly 
of  proteid.  Their  aim  by  means  of  proteid  is  to  neutralize  the 
acid  secretion  as  fast  as  formed.  Frequent  feedings  are  recom- 
mended with  the  same  object. 

Lenhartz  is  one  of  these,  and  his  method  may  be  preferred  for 
some  cases.     His  diet  schedule  follows,  p.  157. 

D.  Reduction  of  gastric  secretion  *  may  be  favored  by  starva- 
tion, by  a  diet  low  in  proteid,  by  the  avoidance  of  salt  and  by 
the  administration  of  \  to  1  tablespoonful  of  olive  oil  several 
times  daily. 

E.  Medication: 

1 .  Sodium  bicarbonate  t  should  be  prescribed  freely  for  relief 
of  pain  or  distress  in  the  dose  of  fr.  \  to  1  teaspoonful,  or  more 
if  required,  in  a  glass  of  water.     A  hot  water  bag  may  relieve. 

2.  After  feeding  has  been  begun  bismuth  subnitrate  should 


*  Small  doses  of  atropine  are  recommended  by  some  physicians, 
t  Magnesium  oxide  is  preferred  by  some  physicians. 


153 


be  given  three  times  daily  in  teaspoonful  doses  before  meals  with 
the  hope  of  benefit  by  coating  the  ulcer  mechanically.  Bismuth 
is  not  constipating  in  this  dose.  It  is  important  that  the  drug 
should  be  pure.* 

3.  The  bowels  should  be  kept  free  by  enema  or  by  mild  cathar- 
tics. Milk  of  magnesia  acts  well  as  a  mild  cathartic  and  also  as 
an  antacid. 

D.  Convalescence: 

1.  General  hygienic  measures  including  attention  to  the 
bowels  are  important. 

2.  Work  should  be  resumed  gradually  and  much  fatigue, 
psychical  more  than  physical,  should  be  avoided. 

3.  Rest,  lying  down,  for  from  |  to  1  hour  after  meals  is  of 
great  benefit. 

4.  Food  should  be  taken  in  the  middle  of  the  morning,  the 
middle  of  the  afternoon  and  at  bedtime  in  addition  to  regular 
meals. 

5.  The  more  strictly  the  diet  and  regimen  can  be  followed 
the  greater  the  chance  of  success  but  it  is  better  to  enlarge  the 
dietary  than  to  undernourish  the  patient  because  good  nutrition 
favors  healing  of  the  ulcer.  The  treatment  should  be  followed 
as  strictly  as  practicable  for  from  six  months  to  a  year. 

COMPLICATIONS:  TREATMENT. 

A.  Hemorrhages,  when  small,  require  no  special  treatment. 

When  a  severe  hemorrhage  occurs  the  patient  should  lie 
as  still  as  possible  and  morphine  should  be  given  subcutaneously 
in  dosage  sufficient  to  bring  the  patient  well  under  its  influence 
and  to  inhibit  peristalsis  (p.  81).  Further  medication  is  not 
likely  to  do  good. 

An  ice-bag  may  be  placed  over  the  stomach. 

Stimulation  of  the  circulation  by  salt  solution,  by  transfusion 
of  blood,  or  by  drugs  should  be  withheld  unless  demanded  by 
immediate  danger,  because  raising  the  blood-pressure  may 
prolong  the  hemorrhage. 

If  syncope  be  feared  after  hemorrhage  it  may  be  advisable  to 
raise  the  foot  of  the  bed. 


Squibb's  is  good  for  this  purpose. 


155 


Operation  is  seldom  indicated  during  hemorrhage  because 
most  hemorrhages  stop  spontaneously,  and  because  when  the 
patient  has  become  exsanguinated  operation  is  dangerous. 

Repeated  hemorrhage  is  an  indication  for  operation  after  the 
patient  has  recovered  sufficiently  from  the  resulting  anemia. 
Transfusion  may  be  advised  to  hasten  recovery  or  to  prepare 
for  subsequent  operation. 

B.  Perforation  may  be  acute  or  subacute.  It  may  lead  to 
general  peritonitis,  to  abscess,  or  to  adhesions  causing  persistent, 
severe  symptoms. 

The  acute  perforations  and  those  with  abscess  formation 
should  receive  prompt  surgical  treatment.  Early  diagnosis  is 
very  important. 

C.  Pyloric  obstruction,  when  severe,  requires  operation. 
Incomplete  obstruction  with  gastric  dilatation  can  often  be  re- 
lieved temporarily  and  sometimes  for  long  periods  by  rest  in 
bed,  lavage  daily  before  breakfast,  and  a  soft  diet  with  limited 
liquids.  Under  such  treatment  the  dilated  stomach  may  con- 
tract and  acute  inflammation  at  the  pylorus  may  subside. 

This  is  an  excellent  preparation  for  operation.  Operation 
should  be  urged  early  for  pyloric  obstruction  because  when 
symptoms  make  it  imperative  the  weakened  condition  of  the 
patient  adds  greatly  to  the  risk. 

D.  Persistent  severe  symptoms  which  do  not  yield  to  medical 
treatment  demand  that  operation  be  seriously  considered. 


157 


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159 

ACUTE   INDIGESTION. 

Pathology:  Probably  irritation,  with  hyperemia,  and  possibly 
with  inflammation  of  the  mucous  membrane  of  the  stomach, 
of  the  intestines  or  of  both. 

Etiology:  1.  Ingestion  of  food  unwholesome  either  in  itself 
or  for  the  individual. 

2.  Excess  of  food. 

3.  Excess  of  alcohol  or  other  beverage. 

Diagnosis  of  indigestion  is  made  by  history  and  by  exclusion. 
Do   not   overlook   the   following   diseases   which   may   cause 
vomiting: 


1. 

Acute  infectious  diseases 

8.  Brain  tumor. 

including  malaria. 

9.  Tabes  dorsalis. 

2. 

Nephritis. 

10.  Angina  pectoris. 

3. 

Pregnancy. 

11.  Chronic    gastric    or   intes- 

4. 

Migraine. 

tinal  diseases. 

5. 

Lead  colic. 

12.  Acute  surgical  conditions, 

6. 

Hysteria. 

e.g.,   appendicitis,    chole- 

7. 

Acute  drug  poisoning. 

cystitis,  renal  colic,  etc. 

PRINCIPLES   OF 

TREATMENT. 

1.  Rest  and  warmth  for  patient. 

2.  Removal  of  cause  of  symptoms. 

3.  Rest  for  digestive  tract. 

4.  Symptomatic  treatment. 

METHODS. 

Methods  must  be  chosen  with  regard  to  the  cause,  severity 
and  nature  of  symptoms. 

1.  Rest  and  Warmth.  The  patient  should  lie  down  and  should 
be  warmly  covered  or  should  remain  in  bed.  Hot-water  bags 
may  be  useful  for  cold  extremities  or  for  abdominal  distress  or 
pain.  Rest  and  warmth  diminish  metabolic  waste  and  promote 
recuperation. 

2.  Removal  of  Cause.  If  the  distress  is  gastric,  and  if  the 
stomach  has  not  been  freely  emptied,  emesis  may  be  induced  by 
administering  quantities  of  warm  water  or  by  means  of  a  tea- 
spoonful  of  mustard-powder  mixed  in  a  cup  of  warm  water. 


161 


If  symptoms  come  from  the  intestine  the  bowel  should  be 
evacuated  unless  profuse  diarrhoea  has  cleared  it  thoroughly. 
A  saline  cathartic,  or  calomel  followed  by  a  saline  cathartic, 
may  be  of  service  if  the  stomach  can  retain  it.  An  enema  may 
be  given  at  any  time  for  prompt  effect  or  if  cathartics  cannot 
be  retained.  Both  emesis  and  catharsis  are  necessary  for  some 
severe  cases. 

3.  Rest  for  Digestive  Tract.  Well-nourished  patients  gen- 
erally do  best  without  food  of  any  kind  for  from  12  to  24  hours. 
Plain  water  or  mineral  water  may  be  allowed  in  small  quantities 
at  short  intervals. 

When  beginning  to  feed  it  is  wise  to  use  liquids,  such  as  beef 
tea,  chicken  broth,  hot  milk  or  orange  juice,  a  few  ounces,  every 
two  hours.  The  nourishment  should  be  increased  in  amount 
and  in  kind  more  or  less  rapidly  according  to  the  physician's 
estimate  of  the  patient's  digestive  capacity.  Hunger  and  a 
clean  tongue  generally  indicate  that  considerable  quantities  of 
food  can  be  assimilated;  whereas  a  coated  tongue  and  disgust 
for  food  mean  the  reverse. 

6.  Symptomatic  Treatment. 

(a)  Nausea  generally  yields  to  rest  and  abstinence  from  food. 
Emesis  is  advisable  for  some  cases. 

(b)  Vomiting  usually  stops  spontaneously  when  the  stomach 
has  been  emptied.  If  it  does  not  yield  to  rest  and  abstinence 
from  food  it  may  be  checked  sometimes  by  a  teaspoonful  of 
shaved  ice  with  brandy,  by  a  drop  of  Tr.  of  iodine  in  a  teaspoon- 
ful of  water,  by  \  gr.  (or  0.016  gm.)  of  cocaine  hydrochloride 
dissolved  in  a  teaspoonful  of  water,  by  1  gr.  (or  0.008  gm.)  of 
morphine  sulphate  absorbed  from  the  mouth,  by  other  drugs, 
or  by  gastric  lavage.  Food  should  be  withheld  entirely  for 
from  about  3  to  12  hours  after  vomiting  has  ceased.  Water 
should  be  allowed  during  this  period  in  very  small  amounts 
if  at  all.     Cracked  ice  may  be  sucked  for  thirst. 

When  gastric  disturbance  lasts  over  a  period  of  days,  salt 
solution  must  be  administered  in  the  form  of  enemata,  by  rectal 
seepage  or  by  hypodermoclysis.  Three  pints  in  24  hours  is 
enough.  These  measures  and  rectal  feeding  are  very  rarely 
needed  in  acute  gastritis. 

Feeding  should  be  resumed  cautiously,  using  milk  diluted 
with  mineral-water,  lime-water,  or  carbonated  water;   or  orange 


163 


juice,  or  broth  in  teaspoonfuls  every  half  hour.  The  quantity 
of  nourishment  should  be  increased  and  the  intervals  between 
feedings  lengthened  gradually. 

(c)  Diarrhoea  should  not  be  checked  until  all  old  fsecal  matter 
has  been  discharged.  If  the  diarrhoea  persists  in  a  mild  form 
a  few  doses  of  about  15  grs.  (or  1  gm.)  of  bismuth  subnitrate  may 
suffice  to  stop  it.  When  diarrhoea  is  severe  opiates  are  often  re- 
quired. A  teaspoonful  of  paregoric  may  be  prescribed  after 
each  loose  movement.  Morphine  may  be  required  subcutane- 
ously.     For  other  medicaments  see  below. 

(d)  Colic  can  be  checked,  when  slight,  by  the  application 
of  heat  to  the  abdomen  and  by  rest  and  abstinence  from  food. 

Paregoric  or  other  preparations  of  opium  or  morphine  may 
be  used  for  severe  pain  but  they  are  contraindicated  in  full 
dosage  until  the  intestinal  tract  has  been  cleared,  and  also 
when  conditions  which  may  require  surgical  interference  cannot 
be  ruled  out. 

SIMPLE   DIARRHOEA. 

DIAGNOSIS. 

Do  not  overlook  the  following  diseases  which  may  cause 
diarrhoea. 

1.  Dysentery,  bacillary  or  amoebic. 

2.  Other  infectious  diseases,  e.g.,  typhoid. 

3.  Nephritis  with  colitis. 

4.  Carcinoma  of  lower  bowel. 

5.  Fsecal  impaction  with  intermittent  diarrhoea. 

6.  Rectal  diseases  with  tenesmus. 

7.  Mucous  colitis. 

8.  Reflex  or  nervous  diarrhoea,  e.g.,  due  to  chill,  exophthalmic 

goitre,  or  perhaps  to  anxiety. 

9.  Habitual  excess  in  eating  and  insufficient  exercise. 

10.  Irritating  ingesta  or  imperfectly  digested  food. 

PRINCIPLES   OF  TREATMENT. 

Suit  methods  to  severity,  duration  aud  persistence  of  symp- 
toms: 

(a)  Remove  irritant,  usually  imperfectly  digested  food. 
(6)  By  means  of  a  suitable  diet  avoid  further  irritation. 


165 


(c)  Limit  peristalsis. 

(d)  When  there  is  toxemia,  dilution  and  elimination  of  toxins 
is  important. 

METHODS. 

A.  To  Remove  Irritant.  Unless  bowel  has  been  thoroughly 
evacuated  prescribe  a  purge  which  will  act  quickly  and  ascer- 
tain that  this  result  has  been  obtained  before  proceeding  to  other 
kinds  of  medication. 

A  saline,  or  castor  oil,  may  be  used.  If  these  are  vomited  an 
enema  may  do  good.  It  may  be  advisable  to  induce  emesis 
(p.  159).     Calomel  generally  acts  well  (p.  211). 

B.  The  Diet  should  be  non-irritating;  should  leave  little  resi- 
due; and,  preferably,  should  be  digested  high  up. 

Eggs,  broths  and  lean  meats  are  well  digested  as  a  rule. 
Starches  containing  little  cellulose  may  be  preferred  occasion- 
ally. 

Fats,  fruits  and  coarse  vegetables  in  general  are  to  be  avoided. 
Liquids  should  be  bland  and  not  cold. 

C.  To  limit  peristalsis,     (a)  Rest,  preferably  in  bed. 

(6)  Restriction  of  ingesta.  Meals  should  be  small  and  fre- 
quent. In  severe  conditions  of  short  duration  food  and  liquids 
may  be  forbidden  entirely  for  a  time.  The  length  of  time  de- 
pends on  the  state  of  nutrition  and  tolerance  of  the  patient. 

(c)  Warmth,  externally  and  internally,  i.e.,  a  warm  room, 
avoidance  of  changes  of  temperature,  a  hot-water  bag  on  ab- 
domen and  hot  drinks. 

MEDICATION. 

(a)  Astringents.  Bismuth  subnitrate,  fr.  10  to  20  grs.  (or  0.65 
to  1.3  gm.)  every  2  to  8  hours. 

Acidum  tannicum  (U.  S.),  boiled  green  tea,  red  wine,  or  Tan- 
nalbin  *  may  be  tried. 

(6)  Sedatives.  Opiates  are  best,  e.g.  Tr.  opii  camphorata 
(U.  S.)  "  Paregoric,"  or  Tr.  opii  deodorati  (U.  S.),  or  Misturae 
contra  diarrhceam  (N.  F.),  as  "  Cholera  mixture,"  "  Squibb's 
Diarrohcea  Mixture,"  and  others,  or  "C.  O.  T.  pill"f  contain- 
ing Camphor  1  gr.  (or  0.065  gm.),  Opium  \  gr.  (or  0.016  gm.), 
and  Tannic  acid  2  grs.  (or  0.13  gm.). 

*  U.  S.  t.  t  Not  official. 


167 

CONSTIPATION. 

Constipation  is  a  symptom  seen  in  many  diseases,  some 
functional,  some  organic.  The  treatment  should  combat  the 
cause  or  causes  in  the  individual  case.  Hence,  a  clear  under- 
standing of  every  case  is  of  prime  importance. 

CLASSIFICATION   OF   CONSTIPATION. 

I.  Spasmodic  Form:  90  per  cent  of  all  cases. 

(a)  Mucous  colitis. 
(6)  Neurasthenia. 

(c)  Lead  poisoning. 

(d)  Intra-abdominal  or  pelvic  inflammation. 

(e)  Fissure  of  anus. 

II.  Atonic  Form. 

Muscular  weakness  or  general  debility  due  to: 

1.  Fevers. 

2.  Anaemia. 

3.  Cachexia. 

4.  Senile  debility. 

III.  Obstructive  Form. 
(a)  Stricture. 

(6)  Adhesions. 

(c)  Pressure  from  tumor  or  pregnancy. 

(d)  Ptosis  with  kink. 

(e)  Acute  obstruction. 

IV.  Less  common  varieties  of  constipation  are  excluded  from 
lack  of  space. 

Diagnosis  of  stricture,  adhesions  and  ptosis  or  kink  can  sel- 
dom be  made  satisfactorily  without  bismuth  x-rays,  but  x-ray 
evidence  is  often  misleading. 

PRINCIPLES   OF  TREATMENT. 

A.  The  essential  causes  of  chronic  constipation  are  neurasthenia 
and  bad  hygiene.  Therefore  it  is  imperative  to  encourage  the 
patient  as  well  as  to  correct  his  habits. 

B.  Clear  the  intestinal  tract  thoroughly  and  keep  it  clear, 
including  the  rectum. 

C.  Soothe  or  stimulate  the  bowel  by  suitable  diet  as  required. 


169 


E.  Use  cathartics  sparingly  or  not  at  all,  and  avoid  undue 
irritation  of  the  bowel  by  them. 

F.  Prescribe  sufficient  liquid  in  definite  quantity. 

G.  Enjoin  proper  mastication  of  food  and  prescribe  false  teeth 
if  needed. 

H.  Instruct  patient  about  regularity  in  defecation. 

1.  Exercise  or  abdominal  massage,  unless  contraindicated, 
may  help  sedentary  persons. 

METHODS   FOR   SPASMODIC   CONSTIPATION. 

Mucous  Colitis.  1.  Non-irritating  diet  composed  chiefly  of 
carbohydrate  with  a  moderate  amount  of  fat  and  a  little  easily 
assimilable  proteid.  Avoid  foods  rich  in  cellulose,  acids,  spices, 
tea,  coffee  and  alcoholic  beverages. 

The  following  list  of  suitable  foods  is  not  complete,  and  should 
not  be  followed  too  closely  in  all  cases.  The  experience  of  the 
patient  may  be  valuable.  Fresh  milk,  cream,  butter,  sugar,  rice, 
macaroni,  sago,  tapioca,  strained  oatmeal,  cream  of  wheat,  white 
bread  or  toast,  potato,  baked,  boiled  or  mashed,  junket,  custard, 
blanc-mange,  eggs,  boiled,  poached,  scrambled  or  shirred,  finely 
minced  chicken  or  lamb,  boiled  tongue,  or  tender  steak  if  it  can 
be  well  chewed.     Do  not  starve  the  patient. 

2.  Bowels  must  be  kept  clear  by  injections  of  oil  in  the  evening 
to  be  retained  during  the  night,  and  by  cleansing  enemata,  pref- 
erably of  warm  normal  salt  solution,  every  morning. 

3.  Cathartics  are  particularly  injurious  to  an  irritated  or  in- 
flamed mucous  membrane  and  abdominal  massage  may  do  more 
harm  than  good.  "  Russian  Oil  "  or  Agar-agar,  p.  217,  act  well 
together  and  are  non-irritating. 

4.  When  the  stools  begin  to  appear  normal  the  regimen  can 
be  relaxed.  Finally,  the  patient  can  drop  the  injections  en- 
tirely and  return  to  a  mixed  diet  rich  in  cellulose  and  fruit  to 
stimulate  normal  defecation. 

5.  Colonic  irrigations  with  or  without  appendicostomy  may 
perhaps  be  tried  in  very  obstinate  cases.  I  have  not  seen  them 
used  and  have  never  advised  them  for  colitis  secondar}^  to  chronic 
constipation. 

Lead  Poisoning  with  Constipation.  Antispasmodic  medi- 
cation with  morphine  or  atropine  is  required. 


171 


Intra-abdominal  or  Pelvic  Inflammation  or  Fissure  of  the 
Anus  may  cause  constipation  by  reflex  spasm.  Treatment  de- 
mands removal  of  the  cause  by  appropriate  means. 

METHODS   FOR   ATONIC   CONSTIPATION. 

~  Post-febrile  constipation,  being  transient,  may  be  treated 
with  mild  laxatives  for  convenience. 

Constipation  in  Anaemia,  Cachexia,  or  Senile  Debility.  The 
patient's  convenience  should  be  considered,  especially  in  am- 
bulatory cases,  or  when  the  chance  of  ultimate  cure  is  small. 
Nux  vomica  may  be  of  service,  and  mild  laxatives,  glycerine 
suppositories,  or  enemata  may  be  advised  according  to  circum- 
stances. Faecal  impaction  should  be  guarded  against  and  watery 
catharsis  must  be  avoided.  Massage  may  do  good  and  mechan- 
ical support  may  aid  defecation  when  the  abdominal  wall  is  weak. 

A  diet,  rich  in  cellulose,  fruits,  and  sugar,  may  help  to  stimu- 
late peristalsis.  Graham  bread,  oatmeal,  cracked  wheat,  green 
vegetables,  beets,  carrots,  turnips,  tomatoes,  raw  or  stewed 
fruits  and  jams  are  particularly  to  be  recommended  for  those 
who  can  digest  them. 

METHODS    OF   TREATMENT   FOR   OBSTRUCTIVE 
CONSTIPATION. 

(a)  Stricture.  Operation  will  generally  be  required.  Palli- 
ation by  means  of  "  Russian  Oil "  by  mouth,  or  by  rectal  injec- 
tions of  oil  followed  by  cleansing  enemata  may  be  beneficial. 

(b)  Adhesions.  The  palliative  measures  just  mentioned  may 
suffice.  Exercise  or  massage  may  do  good.  Operation  may  be 
advisable. 

(c)  Pressure.     Palliate  or  operate  according  to  circumstances. 

(d)  Ptosis.  A  suitable  abdominal  supporter  may  relieve. 
Other  palliative  measures  and  exercise  or  massage  may  help. 
Operation  offers  little  hope  of  relief,  as  a  rule. 

(e)  Acute  Obstruction.     Prompt  operation  is  imperative. 

METHODS   USEFUL  IN   VARIOUS  KINDS   OF 
CONSTIPATION. 

I.  Massage  daily  may  be  very  beneficial. 
"Cannon-ball  Massage."     A  heavy  ball  is  necessary.     A  12- 
or  16-lb.  "shot"  (made  for  athletics)  and  covered  with  leather 


173 


or  strong  cloth  will  serve.  Once  or  twice  daily  the  patient, 
lying  on  his  back,  should  roll  the  shot  repeatedly  around  the 
abdomen  *  from  the  caecum  along  the  course  of  the  colon  for 
15  minutes  before  going  to  the  toilet. 

II.  Enemata.  (a)  In  long-continued  constipation  the  rectum 
may  never  empty  itself  completely  ("dyschezia").  As  a  result 
the  reflex  to  defecation  may  be  lost.  This  reflex  can  sometimes 
be  regained  after  a  course  of  oil  injections  at  night,  followed  by 
cleansing  enemata  in  the  morning.  Olive  or  linseed  oil  is  suit- 
able. From  4  to  6  oz.  (or  fr.  120  to  180  c.c.)  should  be  used  at 
each  injection  and  the  oil  should  be  retained  through  the  night. 

(6)  Cleansing  enemata  of  warm  water  with  the  addition  of 
Sod.  bicarb,  or  of  salt  1  drach.  (4.0  gm.)  to  the  pint  (500  c.c.) 
can  be  used  when  irritation  of  the  mucous  membrane  is  to  be 
avoided. 

(c)  Cold  water,  hot  water,  or  soap  suds  and  water  are  more 
potent  than  salt  solution  or  warm  water. 

(d)  Strong  enemata,  consisting  of  glycerine  fr.  1  drach.  to 
1  oz.  (4  to  30  c.c);  or  of  Sat.  sol.  of  Mag.  sulph.,  glycerine, 
and  water  aa  2  oz.  (or  60  c.c.)  can  be  used  if  required.' 

III.  Laxatives  should  be  used  only  in  conjunction  with  suit- 
able diet,  abundant  liquid  (6  to  S  glasses  of  water  daily)  and 
hygienic  habits.     No  one  laxative  suits  all  persons. 

(a)  Fl.  Ext.  of  Cascara  sagrada  can  be  used  in  doses  of  10  or 
15  min.  (or  0.6  to  1  c.c),  after  meals,  or  in  a  single  dose  of  fr.  10 
min.  to  30  min.  (or  0.6  to  2  c.c.)  at  bed-time.  When  regularity 
of  the  bowels  has  been  established  the  dose  of  Cascara  can  be 
diminished  drop  by  drop  until  medicine  is  no  longer  required. 

(&)  Prunes  and  Senna.  Instruct  patient  to  stew  3  dozen 
prunes  with  two  tablespoonfuls  of  Senna  leaves  (enclose  leaves 
in  a  cheese-cloth  bag),  and  to  eat  10  prunes  once  or  twice  daily. 
When  the  bowels  have  been  regular  for  a  time  the  amount  of 
Senna  can  be  reduced  until  prunes  only  are  taken.  Later, 
the  number  of  prunes  can  be  reduced. 

(c)  Russian  Oil  or  Agar-agar  (p.  217)  may  be  tried.  They  act 
mechanically  and  do  not  irritate  the  intestines. 

*  The  abdominal  muscles  should  be  relaxed  while  the  ball  is  being  rolled. 


CHAPTER    V. 


DRUGS. 

FOREWORD. 

He  who  masters  the  use  of  a  few  good  drugs  will  succeed 
better  than  he  who  tries  many  at  random. 

Before  prescribing  a  drug,  let  the  indications  for  its  use  be 
clear. 

Prescribe  drugs  singly  when  expedient. 

Ascertain  whether  an  idiosyncrasy  to  the  drug  you  wish  to 
prescribe  is  known  to  the  patient. 

When  a  drug  has  been  given,  watch  for  its  good  or  for  its 
toxic  effect.  Increase  dose  until  the  one  or  the  other  is  apparent. 
If  neither  results,  change  either  the  preparation  or  the  drug. 

If  toxic  effects  occur,  omit  the  drug  for  a  time  and  resume  it 
later  in  smaller  dosage  or  try  a  substitute. 

EXPLANATION. 

The  purpose  of  the  list  which  follows  is  to  indicate  the  im- 
portant drugs  and  the  preparation  of  each  believed  to  be  the 
most  generally  useful.  The  dosage  recommended  is  suitable 
for  the  average  adult  and  may  require  modification  for  the  in- 
dividual. 

Much  useful  information  is  contained  in  the  "United  States 
Dispensatory."  It  describes  the  drugs  of  the  principal  phar- 
macopoeias, the  preparations  of  the  "National  Formulary,"  and 
many  unofficial  preparations.  "New  and  Non-official  Rem- 
edies" gives  information  about  many  proprietary  drugs.  The 
writer's  information  about  patents  and  trademarks  was  derived 
from  this  book.  It  is  published  yearly  by  the  American  Medical 
Association. 

175 


177 

ABBREVIATIONS. 

U.  S.     United  States  Pharmacopoeia,  8th  Rev. 

Br.     British  Pharmacopoeia. 

N.  F.     National  Formulary. 

U.  S.  p.  and  t.     United  States  patent  and  trademark. 

N.  N.  R.     New  and  Nonofficial  Remedies,  1914. 

U.  S.  D.     United  States  Dispensatory,  19th  Ed. 


179 

SYNOPSIS    OF   DRUGS. 
I.     SALVARSAN.* 

Action.  Kills  certain  pathogenic  organisms  in  the  living  body. 
It  may  irritate  the  kidneys  or  liver  but  seems  to  have  no  toxic 
effect  per  se  for  other  organs. 

Elimination.  Excretion  rapid,  chiefly  in  urine  and  faeces. 
When  the  excretory  organs  act  normally,  most  of  the  drug  is 
eliminated  on  the  first  day  and  nearly  all  within  three  or  four 
days  after  an  intravenous  injection. 

Toxic  effects.  1.  Signs  of  renal  irritation  or  diminution  of 
kidney  function. 

2.  Jaundice. 

3.  Erythemia. 

4.  Hyperemia  and  swelling  at  the  site  of  syphilitic  lesions; 
i.e.,  "Herxheimer  reaction."  To  this  group  probably  belong 
many  of  the  dangerous  symptoms  arising  within  three  days  of 
the  injection.  Among  them  may  be  mentioned  headache,  vomit- 
ing, earache,  syncope,  convulsions  and  coma. 

5.  Fever  developing  gradually  after  a  day  or  two  may  result 
from  rapid  destruction  of  spirochsetse. 

Accidents  or  errors  which  may  cause  severe  symptoms  or 
death : 

1.  The  "water-error,"  i.e.,  contamination  of  the  distilled 
water  (used  for  solution)  with  bacteria  living  or  dead;  or  with 
chemical  impurities  from  the  distilling  apparatus.  Symptoms 
often  attributed  to  water-error  are  rigor,  rapid  rise  in  tem- 
perature, gastro-enteric  disturbances,  etc.  f 

2.  Impurity  of  NaCl  or  of  NaOH  used  in  the  solution. 

3.  Oxidation  of  the  Salvarsan  may  be  followed  by  signs  of 
arsenical  poisoning,  gastro-enteric  disturbance,  peripheral  neu- 
ritis, paraplegia,  etc. 

4.  Accidental  use  of  an  acid  instead  of  an  alkaline  solution. 
The  former  is  10  times  more  toxic  than  the  latter. 

5.  Errors  in  technic  of  injection;  may  result  in  venous  throm- 
bosis and  pulmonary  embolism. 

*  U.  S.  p.  and  t.  Diarsenol  is  being  extensively  used  as  a  substitute  for 
Salvarsan.     They  are  extremely  similar  if  not  identical  in  action. 

t  There  are  those  who  believe  that  the  symptoms  attributed  to  the  "water- 
error"  are  due  to  other  causes,  e.g.,  overdosage. 


181 


6.  Use  of  Salvarsan  in  unsuitable  cases. 

7.  Lack  of  preparation,  or  of  after-care  of  the  patient. 

8.  Excessive  dosage  for  the  individual  under  existing  circum- 
stances, or  too  early  repetition  of  dose. 

9.  Combined  effect  of  various  factors  above  mentioned. 

10.  Neurorecurrence.  It  appears  after  weeks  or  months  and 
is  a  recurrence  of  syphilis,  not  an  effect  of  Salvarsan. 

Indications.  Suitable  cases  of  syphilis,  relapsing  fever,  yaws, 
and  various  other  diseases.  Salvarsan  is  not  dangerous  when 
used  wisely  and  with  the  best  technic. 

Contraindications  are  relative  rather  than  absolute.  The  use 
of  Salvarsan  is  particularly  dangerous  when  the  patient  has: 

1.  Aneurism,  coronary  sclerosis,  myocarditis,  evidence  of  an- 
gina pectoris,  or  other  severe  lesions  of  the  circulatory  system. 

2.  In  non-s}rphilitic  nephritis. 

3.  In  diseases  of  the  liver,  pancreas,  or  adrenal  glands. 

4.  When  there  is  advanced  degeneration  of  the  nervous  sys- 
tem. 

5.  Profound  anemia,  or  pronounced  cachexia  not  due  to 
syphilis. 

6.  Severe  pulmonary  lesions,  or  marked  physical  weakness 
from  any  cause. 

Caution  is  advisable  when  there  are: 

1.  Syphilitic  lesions  of  the  central  nervous  system,  or  when 
their  presence  is  indicated  by  changes  in  the  spinal  fluid  or 
suggested  by  slight  symptoms. 

2.  In  the  secondary  stage  of  syphilis. 

3.  When  the  patient  is  alcoholic. 

4.  Shortly  after  fatigue  or  exertion. 

5.  When  excess  of  any  kind,  work,  or  travel,  cannot  be  pre- 
vented for  a  time  after  the  injection. 

6.  In  old  age,  or  when  there  is  advanced  arteriosclerosis. 
Administration.     An  infusion  apparatus  consisting  of  a  glass 

receptacle  with  an  opening  at  the  bottom,  a  rubber  tube  provided 
with  a  glass  window  at  the  lower  end,  a  clamp  and  a  needle  will 
suffice.  At  the  Massachusetts  General  Hospital  salt  solution 
is  used  to  establish  the  flow.  When  nearly  all  the  salt  solution 
has  left  the  receptacle  the  Salvarsan  is  poured  in.  Salt  solution 
is  poured  in  again  to  clear  the  needle  before  it  is  withdrawn. 
Care  is  taken  to  prevent  the  entrance  of  air  into  the  vein.     About 


183 


five  minutes  is  allowed  for  the  passage  of  the  Salvarsan  into  the 
vein,  and  the  rate  of  flow  is  regulated  by  the  height  of  the  re- 
ceptacle. 

This  operation  requires  strict  asepsis  at  every  step. 

Dose.  Speaking  of  the  use  of  Salvarsan  in  syphilis,  Ehrlich 
says:  "  The  dose  depends  entirely  on  the  type  and  stage  of  the 
disease."  Ordinarily,  fr.  0.1  to  0.6  gm.*  is  used  at  intervals  of 
from  5  to  10  days.  In  rare  instances"  smaller  or  larger  doses  may 
be  tried. 

Caution.  When  danger  is  to  be  feared  begin  treatment  with 
a  series  of  very  small  doses  at  long  intervals,  or  an  energetic 
course  of  Mercury.  The  combined  use  of  large  doses  of  Sal- 
varsan and  of  Mercury  at  the  same  time  is  believed  to  be  unsafe. 

Note.  —  Alternate  courses  of  Salvarsan  and  of  Mercury  are 
to  be  recommended  for  syphilis. 

NEOSALVARSAN. 

Action.  Like  that  of  Salvarsan  but  less  powerful  in  equal 
dosage. 

Toxic  Effects.  Similar  to  those  of  Salvarsan  but  milder  with 
equal  dosage. 

Indications.  In  may  be  preferred  to  Salvarsan  because  easier 
to  prepare,  or  when  toxic  effects  are  feared. 

Contraindications.     As  for  Salvarsan. 

Administration.  Use  immediately,  because  contact  with  air 
causes  rapid  decomposition.  Do  not  mix  the  drug  until  every- 
thing is  prepared  and  the  needle  already  in  the  vein. 

Dose.  0.9  gm.  of  Neosalvarsan  contains  the  same  quantity 
of  arsenic  as  0.6  gm.  Salvarsan. 

Preparation  of  Alkaline  Solution  of  Salvarsan  for  Intravenous 

Use. 

Printed  instructions  for  preparing  the  solution  are  provided 
with  the  drug. 

Technic  of  the  Massachusetts  General  Hospital. 

1.  Everything  used  for  preparing  the  solution  is  sterilized 
beforehand,  and  is  handled  under  strictly  aseptic  precautions. 

*  The  full  dose  of  0.6  gm.  is  being  used  less  frequently,  and  smaller  doses 
more  frequently  now  at  the  Mass.  Gen.  Hosp. 


185 


2.  The  solution  is  mixed  in  an  8-oz.  bottle  which  should  have 
a  glass  stopper.  The  bottle  is  graduated  for  100  and  200  c.c. 
Similar  ungraduated  bottles  should  be  used  for  dispensing. 

3.  The  drug  is  dissolved  in  the  mixing  bottle  by  hard  shaking 
with  about  50  c.c.  of  0.6  per  cent  salt  solution  instead  of  dis- 
tilled water.  Solution  takes  place  rapidly  without  the  aid  of 
beads. 

4.  To  a  dose  of  0.6  gm.  of  Salvarsan  thus  dissolved  5  c.c.  of 
normal  NaOH  solution  is  added  and  the  mixture  is  again  shaken 
until  perfectly  clear.  Salt  solution  is  then  added  to  make  200 
c.c;  the  dispensing  bottle  is  rinsed  with  the  solution;  the 
solution  is  filtered  back  into  the  dispensing  bottle,  and  after  in- 
sertion of  the  stopper,  the  neck  of  the  bottle  is  covered  with 
sterile  gauze,  which  is  held  in  place  by  a  pin.  The  drug  is  then 
ready  for  use. 

Salvarsan  may  decompose  within  a  few  hours.  It  should  be 
kept  cool  until  needed,  and  should  then  be  warmed  only  a  little. 

List  of  Things  Required  for  Preparing  Solution. 

1.  Burette  graduated  to  c.c,  containing  normal  NaOH  solu- 
tion. 

2.  Flask  of  0.6%  NaCl  solution. 

3.  Glass  funnel  and  filter  paper. 

4.  One  graduated  and  one  plain  8-oz.  bottle  having  glass 
stoppers. 

5.  Basin  of  antiseptic  containing  also  the  ampule  of  Sal- 
varsan, a  file  and  a  pin. 

6.  Sterile  sheet  and  sponges. 

2.  HYDRARGYRUM. 

"  Mercury." 

(a)  Hydrargyri  salicylas.*     "  Neutral  mercuric  salicylate." 
(6)  Hydrargyri   chloridum   corrosivum    (U.    S.).     "  Corrosive 
sublimate,"  "  Bichloride  of  mercury." 

(c)  Unguentum hydrargyri  f  (U.  S.).     "Mercurial  ointment." 

*  Not  official  in  U.  S.  There  is  also  a  basic  salicylate  of  mercury  (Merck)- 
It  is  used  at  the  Massachusetts  General  Hospital. 

t  Conts.  about  50%  of  Mercury  by  weight.  Ung.  Hydrarg.  Dil.  (U.S.), 
*'  Blue  ointment,"  conts.  about  33%  of  Mercury. 


187 


(d)  Hydrargyri  iodidum  flavum  (U.  S.).  "  Protiodide  or 
yellow  iodide  of  Mercury." 

Action  of  the  above  preparations  is  essentially  the  same: 
anti-syphilitic,  local  irritant,  and  antiseptic. 

Elimination.  Chiefly  by  intestines  and  kidneys;  also  in 
saliva.     Excretion  is  slow. 

Toxic  Effects:  Acute  Poisoning:  stomatitis,  salivation,  renal 
irritation,  diarrhoea,  abdominal  pain  and  gastric  disturbance. 

Chronic  Poisoning:   cachexia,  anemia,  etc. 

Indications:  Syphilis.  The  choice  of  a  mercurial  prepara- 
tion depends  on  the  stage  and  severity  of  the  disease,  the 
condition  of  the  patient,  and  the  circumstances  under  which 
the  treatment  is  to  be  carried  out.  Each  of  the  four  preparations 
mentioned  above  has  advantages  lacking  in  the  others. 

Contraindications.     Nephritis  unless  luetic,  cachexia,  anemia. 

Administration  and  Dose. 

(a)  Hydrargyri  salicylas:  nearly  insoluble;  single  dose  fr.  10 
to  15  min.  (or  0.6  to  1  c.c.)  of  a  10  per  cent  emulsion  of  the  drug 
in  Petrolatum;  repeat  in  from  5  to  10  days.  Inject  into  the 
gluteal  muscle.     Use  a  platinum  needle  1§  in.  long. 

(b)  Hydrargyri  chloridum  corrosivum:  soluble;  single  dose 
fr.  7  to  15  min.  (or  0.5  to  1  c.c.)  of  a  1  per  cent  solution  of  the 
drug  in  a  10  per  cent  watery  solution  of  Sodium  chloride;  repeat 
in  1  or  2  days.  Inject  into  the  gluteal  muscle.  Use  a  platinum 
needle. 

(c)  Unguentum  hydrargyri:  administer  by  inunction.  Dose 
fr.  |  to  1  drach.  (or  2  to  4  gm.).  Efficiency  depends  much  on 
thoroughness  of  application. 

(d)  Hydrargyri  iodidum  flavum;  administer  in  pills  by 
mouth.  Dose:  i  gr.  t.  i.  d.  (or  0.013  gm.)  and  upward,  increas- 
ing gradually  until  the  first  signs  of  intolerance  appear.  Then 
reduce  dose  by  half  and  continue. 

Caution.  When  mercurials  are  given,  the  mouth  must  be 
kept  scrupulously  clean  to  avoid  stomatitis.  Teeth  should  be 
brushed  and  throat  gargled  after  every  meal.  If  there  is  pyor- 
rhoea alveolaris,  the  gums  may  be  scrubbed  with  castile  soap 
or  swabbed  daily  with  a  1  per  cent  solution  of  Potassium  per- 
manganate, applied  with  cotton  stick;  also  rinse  or  spray  mouth 
with  Hydrogen  peroxide.  When  giving  the  Protiodide  of 
Mercury  and  Sodium  or  Potassium  iodide  also,  give  the  Pro- 


189 


tiodide  a.  c.  and  the  Potassium  iodide  p.  c.  to  prevent  formation 
of  the  Biniode  of  Mercury.  When  using  large  doses  of  any 
mercurial,  the  bowels  should  be  kept  clear,  and  the  food  should 
be  readily  digestible,  nutritious  and  ample  in  quantity. 

Note.  —  The  reader  is  advised  not  to  use  Mercury  in  large 
doses  or  by  injection  unless  familiar  with  the  details  of  its  ad- 
ministration, dosage  and  indications.  Gottheil  gives  an  ex- 
cellent account  in  Forchheimer's  "  Therapeusis  of  Internal 
Diseases." 

3.   POTASSII   IODIDUM.     (U.  S.) 
11  Iodide  of  Potash." 

Properties.     White,  crystalline,  very  soluble  in  water. 

Action.  1.  Causes  disappearance  of  gummata;  but  a  lesion 
which  disappears  while  iodides  are  being  taken  is  not  necessarily 
syphilitic. 

2.  Increased  fluidity  of  mucus  in  respiratory  tract.* 

3.  Seems  to  increase  thyroid  activity. 

Elimination.     Rapid,  chiefly  in  urine  as  salts,  partly  in  saliva.* 
Toxic  Effects:   Acute:  Acne,  erythema,  and  other  serious  skin 
lesions,    catarrh    of    respiratory    organs,    gastric    disturbances, 
delirium,  etc.     Chronic:   loss  of  weight,  nervousness,  anemia. 
Indications.     1.  Late  stages  of  syphilis. 

2.  Bronchitis  with  sticky  expectoration. 

3.  Empirically  in  arteriosclerosis,  asthma,  lead  poisoning, 
simple  goitre,  and  many  other  conditions. 

Contraindications.  Acute  renal  irritation,  acute  inflammation 
of  the  respiratory  tract,  and  "  hyperthyroidism."  It  may  be 
harmful  in  phthisis. 

Administration.  1.  For  syphilis,  fr.  10  to  20  grs.  (or  0.6  to 
1.3  gm.)  t.  i.  d.  p.  c.  in  milk.  For  syphilis  of  central  nervous 
system,  increase  dose  rapidly  until  benefit  or  iodism  results. 
One  hundred  grains  (or  6.5  gm.)  t.  i.  d.  is  large  enough  dosage. 
The  sat.  sol.  in  water  is  convenient:     1  min.  =  1  gr.  or  0.065  gm. 

2.  As  expectorant  give  fr.  5  to  10  grs.  (or  0.3  to  0.6  gm.) 
t.  i.  d.  p.  c.  well  diluted. 

3.  For  empirical  action  use  small  doses. 

*  Bastedo. 


191 


Substitutes.  For  syphilis:  other  preparations  of  Iodine, 
Mercury,  or  Salvarsan. 

As  expectorant:  Ammonium  chloride. 

4.  DIPHTHERIA   ANTITOXIN.* 

Action.     Curative  in  diphtheria. 

Absorption.  It  is  absorbed  slowly  from  the  subcutaneous 
tissues,  the  process  lasting  for  several  days. 

Toxic  Effects.     Urticaria,  erythema,  joint-pains,  etc. 

Indications.  Clinical  diphtheria;  and  for  those  exposed  to 
diphtheria. 

Contraindications.  Never  absolute.  Dangerous  in  sufferers 
from  horse  asthma.  It  is  doubtful  whether  a  single  dose  of 
antitoxin  ever  produces  sensitization  in  humans  sufficient  to 
cause  anaphylactic  shock  on  administering  a  second  dose. 

Administration.  By  injection  into  the  loose  subcutaneous 
tissues  of  the  abdominal  wall  or  below  the  angle  of  the  scapula. 

Intravenous  injections  are  best  for  severe  cases. 

Dose.  The  dose  should  be  gauged  according  to  the  severity 
of  symptoms,  duration  of  illness,  and  extent  and  location  of  the 
membrane.*  Large  doses  are  indicated  when  the  larnyx,  trachea, 
or  nasopharynx  is  much  involved,  and  especially  in  virulent 
diphtheria. 

Therapeutic  dose  for  adults,  fr.  5000  to  100,000  units.  For 
immunization,  fr.  1000  to  2000  units. 

5.  MORPHINE   SULPHAS.     (U.  S.) 
11  Morphine  "  or  "  Morphia." 

Properties.  White,  crystalline,  soluble  in  about  sixteen  parts 
water;  less  soluble  in  alcohol. 

Action.  1.  Diminishes  sensibility  to  lasting  impressions  and 
stimuli.     (Sollmann.) 

2.  Relieves  pain. 

3.  Slows  respiration  and  heart-action.     (Bastedo.) 

4.  Diminishes  metabolism. 


*  Manufactured  by  Departments  of  Health  and  by  pharmaceutical  firms. 
It  can  be  obtained  from  the  State  Board  of  Health  in  Massachusetts  free  of 
charge. 


193 


5.  Diminishes  peristalsis;   therefore,  constipating. 

6.  In  acute  cardiac  dilatation  gives  relief. 

7.  In  colic  or  intestinal  spasm  it  may  act  as  a  cathartic. 
Elimination.     Chiefly    by    gastro-intestinal    tract.     Some    is 

oxidized  in  the  body. 
Toxic  Effects.     1.  Somnolence  or  stupor. 

2.  Respiration  very  slow  and  may  become  shallow  and  ir- 
regular (Cushny). 

3.  Pupillary  contraction. 

4.  Flushing  or  cyanosis  of  face. 

5.  Retention  of  urine. 

6.  During  recovery  from  drug  nausea  is  common. 

7.  Death  results  from  depression  of  respiratory  center. 
Indications.     Acute  conditions  with,  — 

1.  Severe  pain. 

2.  Discomfort  preventing  sleep. 

3.  Acute  cardiac  insufficiency. 

4.  Internal  hemorrhage  (gastric,  pulmonary,  intestinal). 

5.  Persistent  vomiting. 

Contraindications.*  1.  Danger  of  forming  habit.  In  chronic 
or  recurring  non-fatal  diseases,  and  in  conditions  which  can  be 
relieved  by  milder  means,  use  morphine  with  caution  if  at  all. 

2.  When  bronchial  secretion  is  profuse,  morphine  may  prevent 
necessary  expectoration:   see  pneumonia,  p.  123. 

3.  Idiosyncrasy:   causes  excitement,  vomiting,  depression. 
Administration.      For    urgent     conditions     give     subcutane- 

ously  in  the  dose  of  fr.  §  to  \  gr.  (or  0.008  to  0.032  gm.),  with 
or  without  atropine  sulphate,  fr.  ihn  to  xstt  gr-  (°r  0.00032  to 
0.00052  gm.).  Morphine  is  generally  given  by  mouth  in  tablet, 
in  watery  solution,  or  in  a  mixture.  Morphine  can  be  absorbed 
from  the  mouth  and  will  then  act  more  quickly  than  if  swallowed. 
Atropine  given  with  morphine  tends  to  diminish  the  gastric 
disturbance  which  may  follow.  Atropine  produces  toxic  symp- 
toms if  repeated  often. 


*  Codman  believes  that  morphine  after  abdominal  operations  may  in- 
duce gastric  dilatation;  and  Bastedo  says  it  should  not  be  used  when  there 
is  "much  depression  of  respiration,  as  in  edema  of  the  lungs,  Cheyne-Stokes 
breathing  and  some  cases  of  pneumonia,"  or  in  "acute  dilatation  of  the  stomach 
or  bowels."  "It  should  be  employed  cautiously  in  nephritis,  especially  if 
there  is  any  uremic  tendency,"  and  in  "infancy  and  old  age." 


195 


Substitutes.     Opium  in  pill,  as  tincture,  or  in  suppository. 

1.  Pilula?  opii  (U.  S.):  conts.  opium  1  gr.  (or  0.065  gm.) 
(=  morphine  |  gr.  or  0.008  gm.). 

2.  Tinctura  opii  deodorati  (U.  S.).  Dose  fr.  5  to  15  m.  (or 
0.3  to  1  c.c). 

3.  Tinctura  opii  camphorata  (U.  S.)  —  "  Paregoric."  Dose 
for  adult  fr.  1  to  4  dr.  (or  4  to  16  c.c). 

4.  Codeinic  sulphas  (U.  S.).     i  to  |  gr.  (or  0.008  to  0.032  gm.). 

5.  Heroine  hydrochloride,  the  diacetic  ester  of  morphine,  not 
official;  dose  xV  gr.  (0.006  gm.). 

6.  Hyoscinae  hydrobromidum  (U.  S.).  Dose  fr.  xltf  to  rthr  gr. 
(or  0.00033  to  0.00065  gm.)  subcutaneously.  Combined  with 
morphine  it  may  act  better  than  either. 

6.  TINCTURA  DIGITALIS.     (U.   S.) 
"  Tincture  of  Digitalis."  * 

Action.     1.  Increases  force  of  cardiac  systole. 

2.  Lengthens  diastole  and  slows  heart  action. 

3.  Raises  blood-pressure  if  pressure  is  low. 

4.  Promotes  diuresis  when  there  is  dropsy. 

Absorption  slow;  therefore  24  hours  or  more  is  required  for 
result.     Action  may  be  cumulative  because  excretion  is  slow. 

Toxic  Effects.  Tachycardia  or  bradycardia  with  irregularity, 
heart-block,  pulsus  alternans,  fall  of  blood-pressure,  oliguria, 
vomiting,  headache. 

Indications.  Myocardial  insufficiency  in  general,  with  or 
without  valvular  disease.  Almost  useless  in  circulatory  weak- 
ness resulting  from  vascular  dilatation  or  from  depletion. 

Tachycardia,  per  se,  does  not  call  for  digitalis. 

Contraindications.  When  increase  of  blood-pressure  would 
be  dangerous,  e.g.,  cerebral  hemorrhage. 

When  heart-block  is  developing  use  digitalis  cautiously  if  at  all. 

Administration.     Prescribe  with  water  p.  c. 

Ordinary  dose:  fr.  5  to  20  m.  t.  i.  d.  (or  0.32  to  1.3  c.c).  If 
preparation  is  weak,  higher  dosage  may  be  required.  Tincture 
should  be  assayed  physiologically. 

*  Parke,  Davis  &  Co.  and  Burroughs,  Welcome  &  Co.  and  Squibb  assay 
their  tinctures  physiologically  I  have  used  the  former  and  found  it  good. 
The  others  are,  probably,  equally  reliable.  Powdered  leaves  in  pills  of  1  gr^ 
each  may  be  preferred. 


197 


When  quick  action  is  required,  fr.  20  to  30  min.  (or  1.3  to 
2  c.c.)  may  be  injected  intramuscularly.     It  is  a  local  irritant. 

To  prevent  cumulative  effect,  keep  bowels  free. 

Substitutes.  1.  "  Digipuratum."*  Dose  fr.  1  to  4  tablets 
in  twenty-four  hours.  Each  tablet  contains  \\  grs.  (or  0.097 
gm.)  of  digipuratum  and  is  about  equal  in  strength  to  15  m. 
(or  1  c.c.)  of  the  most  active  tincture  of  digitalis.  Its  thera- 
peutic action  is  like  that  of  the  tincture  but  the  effect  comes  more 
quickly  and  digestive  disturbance  is  rare.  This  drug  should  act 
in  fr.  12  to  24  hours. 

"  Digipuratum-solution "  can  be  obtained  in  vials,  each 
containing  1|  grs.  (or  0.097  gm.)  of  the  drug,  and  this  dose,  or 
half  of  it,  can  be  injected  intramuscularly.  The  effect  can  then 
be  expected  in  about  half  an  hour.  The  same  preparation  acts 
in  about  10  minutes  when  used  intravenously.  The  injection 
should  be  given  very  slowly.  Single  doses  of  fr.  f  to  1|  grs. 
(or  0.05  to  0.097  gm.)  can  be  used  intravenously. 

2.  Strophanthinum  (U.  S.).f  Action  on  heart  is  like  digi- 
talis but  effects  are  sudden  and  profound.  Death  may  result 
if  the  patient  has  taken  any  preparation  of  the  digitalis  group 
within  one  week.  On  account  of  local  irritant  action  strophan- 
thin  should  be  used  intravenously,  and  to  avoid  shock  the  in- 
jection should  be  given  very  slowly  over  a  period  of  not  less  than 
5  minutes.     Dose  fr.  0.0005  to  0.001  gm. 

7.  NITROGLYCERIN.^ 
"  Glonoin,"  "  Trinitrin." 

Action.  Lowers  blood-pressure  by  dilating  peripheral  ves- 
sels. Acts  within  a  few  minutes;  effect  lasts  about  \  hour. 
In  the  presence  of  hypertension  diuresis  may  result. 

Toxic  Effect-  Flushing,  sense  of  fulness  in  head,  throb- 
bing headache,  faintness.     Reduction  of  urinary  output. 

Indications.     Angina  pectoris. 

Cardiac     embarrassment         ,        ,      ,     ,  .  . 

„     ,     ,  \  when  due  to  high  pressure. 


*  U.  S.  p.  and  t.;  very  expensive.  Caesar  &  Loretz  powdered  digitalis  leaves 
are  good*  and  less  expensive.  Digifoline  (Ciba)  is  now  being  tried  as  a  sub- 
stitute for  digipuratum  which  is  very  difficult  to  obtain. 

t  Boehringer's  is  good.  It  is  marketed  in  vials  containing  0.001  gm.  of  the 
drug  in  solution. 

%  Official  only  in  the  form  of  Spiritus  glycerilis  nitratis  (U.  S.) 


199 


Contraindications.     Low  blood-pressure. 

Administration.  Tablet  triturate.*  For  quick  absorption  the 
tablet  should  be  chewed  and  not  swallowed. 

Ordinary  dose,  xltar  gr.  (or  0.00065  gru.)  may  be  repeated  fre- 
quently unless  toxic  symptoms  result. 

For  some  cases  slnr  gr.  (or  0.00032  gm.),  or  ■£%  gr.  (or  0.0013 
gm.)  is  better.     Larger  doses  may  be  required. 

Substitutes.     1.  Amylis  nitris  (U.  S.).     "  Amyl  nitrite." 

Dose  3  to  5  min.  (or  0.18  to  0.3  c.c). 

Acts  very  rapidly.     Effect  very  transient. 

May  act  when  nitroglycerin  fails. 

Put  up  in  "  pearls  "  containing  3  or  5  min.  (0.2  or  0.3  c.c.) 

Break  pearl  and  inhale  from  handkerchief. 

Pearls  f  should  break  easily  but  not  spontaneously. 

2.  Sodii  nitris  (U.  S.).     "  Sodium  nitrite." 

Action  like  nitroglycerin,  but  lasts  longer. 

Best  prescribed  in  watery  solution. 

Dose,  2  grs.  (or  0.13  gm.). 

8.  "THEOBROMINE   SODIUM   SALICYLATE.''^ 

Properties.  White  pwd.  v.  sol.  in  water,  taste  unpleasant, 
turn  brown  on  exposure  to  air. 

Action.  Diuretic;  slightly  irritating  to  the  kidneys.  Effect 
is  produced  in  from  twelve  to  forty-eight  hours;  lasts  for  from 
two  to  three  days. 

Toxic  Effect.     Vomiting. 

Indications.  Cardiac  dropsy.  (Useless  or  nearly  so  in  pure  renal 
dropsy.)    Small  doses  sometimes  act  well  in  angina  pectoris,  p.  39. 

Contraindications.     Acute  nephritis. 

Administration.     In  capsules  or  in  a  cachet  p.  c. 

Dose,  15  grs.  (or  1  gm.)  4  i.  d.  If  no  result  after  48  hours, 
double  dose.  Never  prescribe  it  in  these  doses  for  more  than  3 
days  at  a  time. 

Substitutes.  1.  Fluidextr actum  apocyni  (U.  S.)  or  "  Cana- 
dian hemp."  Action  diuretic  and  like  that  of  digitalis  but 
milder.     Dose,  fr.  5  to  15  m.    (or  0.3  to  1  c.c).     Effects  oc- 

*  Tablets  lose  strength  in  time.     To  test  them  take  |  tablet  yourself. 

t  Allen  &  Hanbury's  are  good. 

t  A  double  salt  of  theobromine-sodium  and  sodium  salicylate.  It  is  official 
in  Germany  (N.N.R.).  "Diuretin"  is  the  "trade  name"  of  a  similar  pro- 
prietary remedy. 


201 


casionally    dangerous.     Better   prescribed    as    a   fresh   infusion 
(Wheatley)  corresponding  dose,  fr.  5  to  10  min.  (or  0.3  to  0.6  c.c). 

2.  Theophylline.*  Dose  fr.  3  to  6  grs.  (or  0.2  to  0.4  gm.) 
t.  i.  d   in  powder  with  water  or  in  capsule. 

3.  If  kidneys  are  sound,  Calomel  may  be  used  in  the  dose  of 
3  grs.  (or  0.2  gm.)  every  four  hours  for  from  twenty-four  to  forty- 
eight  hours  or  even  longer.  To  reduce  danger  of  salivation  take 
precautions  described  under  Hydrargyrum. 

9.  MAGNESII  SULPHAS.     (U.  S.) 
"Salts,"  "  Epsom  Salts"  or  "  Bitter  Salts." 

Properties.  Colorless,  crystalline,  very  soluble  in  water,  taste 
bitter. 

Action.  Hydrogogue  purge  in  concentrated  solution,  cathartic 
in  dilute  solution. 

Toxic  Effects.  Gastric  irritation  and  vomiting.  If  given  in 
concentrated  solution  it  may  be  absorbed  and  may  then  cause 
severe  poisoning  characterized  by  oliguria,  hematuria,  slow 
respiration,  paralysis  of  the  intestines,  extreme  weakness  and 
collapse,  f  The  urine  in  poisoning  shows  a  very  high  specific 
gravity  owing  to  the  excretion  of  the  drug  by  the  kidney.  These 
effects  are  rare. 

Indications.     Dropsy  or  uremic  states. 

Contraindications.  Weakness,  emaciation,  vomiting,  men- 
struation, pregnancy. 

Administration.  Most  easily  taken  in  a  cup  of  black  coffee 
and  most  effective  when  taken  1  hour  before  breakfast  or  when 
the  stomach  is  empty. 

Dose.  From  |  to  1  oz.  (or  15  to  30  gm.)  followed  by  half  a 
glass  of  water.  Small  doses  with  much  water  can  be  used  for 
mild  catharsis. 

Substitutes.  1.  Croton  oil,  fr.  1  to  3  min.  (or  0.06  to  0.2  c  c.) 
in  pellet  of  butter.  If  placed  on  the  back  of  the  tongue  of  an 
unconscious  patient  it  will  be  swallowed. 

2.  Pot.  bitartrate  and  Comp.  jalap,  pwd.  aa  drach.  1  (or  4  gm.). 

3.  Elaterium  (Br.)  1  gr.  (or  0.016  gm.)  in  tablet. 

4.  "  Ten-ten,"  calomel  and  jalap,  aa  grs.  10  (or  0.65  gm.). 

*  Not  official.  Under  the  name  of  "Theocin"  it  bears  U.  S.  p.  and  t. 
(N.N.R.). 

t  Boos:  Jr.  A.M.A.,  Dec.  10,  1910. 


203 

10.  QUININE    SULPHAS.     (U.  S.) 
"  Quinine." 

Properties.  White,  cryst.,  slightly  sol.  in  water,  taste  very 
bitter. 

Action.  Specific  for  malaria,  antipyretic;  readily  absorbed, 
and  rapidly  eliminated  in  urine. 

Toxic  Effects.  Tinnitus,  headache,  vomiting,  erythema; 
occasionally  renal  irritation,  amblyopia,  or  cardiac  depression. 

Indications.     Malaria. 

Contraindications.  Idiosyncrasy  but  patients  are  frequently 
mistaken  in  believing  they  cannot  take  quinine. 

Administration.  In  capsule  p.  c.  Dose,  fr.  5  to  10  grs.  (or 
0.32  to  0.65  gm.)  from  2  to  4  i.  d.  Larger  doses  may  be  re- 
quired. 

Substitute.  1.  Quininse  hydrochloridum  (U.  SO*  fr.  7  to 
10  grs.  (or  0.5  to  0.65  gm.)  daily,  dissolved  in  water  and  given  in- 
tramuscularly, or  30  grs.  (or  2  gm.)  in  enema  (Manson). 

2.  Craig  recommends  for  pernicious  malaria  intramuscular  in- 
jections of  Quinine  bihydrochloride f  grs.  7h  (or  0.5  gm.)  dis.  in 
water,  15  min.  (or  1  c.c.)  and  repeated  every  4  hours  if  necessary. 

3.  Quinine  and  urea  hydrochloride  f  is  more  soluble  and  has 
been  recommended  in  recent  years.  It  is  much  used  in  surgery 
as  a  local  anaesthetic  and  can  be  obtained  in  sterile  solution  in 
vials. 

ii.     SODII   SALICYLAS.     (U.S.) 

Properties.  A  white  powd.  sol.  in  water,  taste  sweetish  and 
saline. 

Action.  Analgesic,  antipyretic,  and  diaphoretic.  It  has  a 
curative  effect  in  some  forms  of  rheumatism.  It  increases 
nitrogen  elimination  in  the  urine  and  acts  as  a  cholagogue  and 
diuretic.     It  is  readily  absorbed  and  is  eliminated  by  the  kidney. 

Toxic  Effects.  Tinnitus,  headache,  vomiting,  erythema, 
delirium  and  gastro-enteric  disturbance.  It  is  slightly  irritating 
to  the  kidneys  and  unless  given  with  alkali  may  cause  albumin- 
uria.    Very  large  doses  may  cause  drowsiness  or  coma. 

*  Soluble  in  35  parts  water, 
t  Not  official. 


205 


Indications.  Rheumatic  fever  and  various  forms  of  "  rheu- 
matism." Useless  in  the  gonorrhceal  and  in  some  other  types 
of  arthritis. 

Contraindication.     Acute  nephritis  or  idiosyncrasy. 

Administration.  In  tablet  or  capsule  followed  by  a  full  glass 
of  water  unless  the  heart  be  insufficient.  If  large  doses  are  to 
be  used  prescribe  also  enough  sodium  bicarbonate  to  render 
the  urine  alkaline  and  see  that  the  bowels  be  kept  free. 

Dose.  For  rheumatic  fever,  10  grs.  (or  0.65  gm.)  of  sodium 
salicylate  every  hour  until  the  patient  is  relieved  of  pain;  then 
10  gr.  (or  0.65  gm.)  every  4  hours  until  convalescence  has  been 
established;  then  fr.  20  to  30  grs.  (or  1.3  to  2  gm.)  daily  for  a 
month  or  more  to  prevent  relapse.  If  toxic  effects  occur  the 
medicine  must  be  omitted  until  they  pass  off.  It  can  then  be 
resumed  in  smaller  dosage  or  in  different  form.  A  vehicle, 
such  as  essence  of  pepsin,  may  be  helpful.  For  mild  cases  of 
arthritis  smaller  doses  may  be  sufficient.  In  chronic  "  rheu- 
matism" fr.  5  to  10  grs.  (or  0.3  to  0.65  gm.)  taken  fr.  2  to  4  i.  d. 
may  promote  comfort. 

Substitute.  1.  Salicinum.  (U.  S.)  Action  and  uses  like  so- 
dium salicylate  but  weaker  and  causes  less  gastric  disturbance. 

2.  Oleum  gaultherise.  (U.  S.)  "  Oil  of  wintergreen."  Should 
be  given  in  milk,  or  in  capsule.  Dose,  fr.  15  to  30  min.  (or  1 
to  2  c.c). 

Aspirin:*  Acetylsalicylic  acid.  Incompatible  with  heat,  mois- 
ture, alkalies,  their  carbonates  and  bicarbonates  (N.N.R.)  Dose 
as  for  sodium  salicylate. 

12.     HEXAMETHYLENAMINA.     (U.  S.)t 

Properties.     Crystalline,  readily  sol.  in  water. 

Excretion.  Chiefly  in  the  urine  in  the  form  of  ammonia  and 
formaldehyde  or  unchanged. 

Action.  When  formaldehyde!  is  set  free  it  acts  as  a  urinary 
antiseptic.  When  the  drug  is  excreted  unchanged,  as  often 
happens,  it  is  inefficient.     It  acts  only  in  an  acid  urine. 


*  U.  S.  p.  and  t. 

t  "Urotropine,"  "Formin,"  and  "Aminoform"  are  proprietary  names  ap- 
plied to  Hexamethylenamina.     (N.N.R.) 
%  May  give  Fehling's  reaction.     (Bastedo.) 


207 


Toxic  Effects.  Renal  irritation  and  hematuria,  painful  mic- 
turition and  pain  in  the  region  of  the  bladder. 

Indications.  Especially  useful  in  typhoid  fever  to  prevent 
bacilluria  and  cystitis.  It  may  act  well  in  other  cases  of  cystitis 
or  pyelitis. 

Contraindication.     Acute  nephritis. 

Administration.  In  capsule  or  tablet.  Dose  from  5  to  10 
grs.  (or  0.3  to  0.6  gm.)  t.i.  d.  with  a  full  glass  of  water.  When 
the  urine  is  alkaline  or  neutral,  acid  sodium  phosphate  in  the 
dose  of  10  grs.  (0.65  gm.)  or  more  if  needed  can  be  prescribed  to 
change  its  reaction,  but  this  drug  should  not  be  administered  with 
Hexamethylenamine  because  they  are  incompatible  (Bastedo). 


209 

VALUABLE   DRUGS. 

13.  Pilulse  ferri  carbonatis.     (U.  S.)    "  Blaud's  Pill." 

Action:   rubefacient,  slightly  constipating,  turns  stools  black. 

Used  especially  in  chlorosis  and  secondary  anemias. 

Dose:  pills  of  5  grs.  each  (or  0.3  gm.);   fr.  1  to  2  t.  i  d  ,  p.  c. 

Substit.  1.  Ferrum  reductum.  (U.  S.)  Dose,  1  to  3  grs. 
(0.065  to  0.20  gm.)  3  or  4  i.  d.  in  pill  or  powd. 

2.  Liquor  ferri  et  ammonii  acetatis.  (U.  S.)  "  Basham's 
mixture."     Dose,  1  dr.  (or  4  c.c). 

14.  Sulphonethylmethanum.     'U.S.)    "  Trional." 
Action:  hypnotic,  sol.  in  195  water,  more  soluble  in  alcohol. 
Toxic  Effect:  somnolence  and  mental  and  physical  depression. 
Used  for  wakefulness,  sometimes  for  alcoholic  delirium. 
Dose:   for  sleep,  fr.  5  to  15  grs.  (0.3  to  1  gm.)  in  powd.  by 

mouth.     Larger  doses  may  be  used  for  delirium. 

Prescribed  in  powder  by  mouth  with  water  or  in  sol.  by  rectum. 

Substit.  "  Veronal."  (U.  S.  pat.)  Dose,  as  for  trional  in 
powd.  or  tab. 

15.  (a)    Sodii  bromidum.      (U.  S.)     "  Sodium  bromide." 
(b)  Potassii  bromidum.      (U.  S.)      "  Potassium  bro- 
mide." 

Action:  Mild  sedative,  lessens  reflex  excitability.  Slightly 
irritating  to  the  stomach. 

Toxic  Effect:     Vomiting,  acne,  coryza,  somnolence. 

Used  for  nervousness,  wakefulness,  epilepsy,  and  to  ward  off 
alcoholic  delirium. 

Dose:  Usually  fr.  5  to  15  grs.  (or  0.3  to  1  gm.  )  t  i.  d.,  or  a 
single  dose  at  night  for  sleep. 

Much  larger  doses  may  be  required  for  epilepsy  and  for  al- 
coholic patients. 

Prescribed  in  watery  solution  by  mouth  well  diluted  and  p.  c, 
or,  occasionally,  by  rectum. 

16.  Acetphenetidinum.     (U.S.)    "  Phenacetin."  * 

Action:     analgesic,  antipyretic,  mild  diaphoretic,  and  sedative. 

Toxic  Effect:     circulatory  depression. 

Used  especially  for  migraine  and  occasionally  for  other  painful 
conditions. 


*  Bayer's  is  the  best. 


211 

Dose:  fr.  5  to  15  grs.  (or  0.3  to  1  gm.)  in  tab.  or  powder.  A 
small  dose  may  be  repeated  in  an  hour  or  more  if  necessary. 
Prescribe  with  caffein  citrate,  1  gr.  (or* 0.065  gm.). 

17.  Pulvis  ipecacuanhas  et  opii.  (U.S.)  "Dover's 
Powder." 

Action:  mild  opiate:  hypnotic,  sedative,  diaphoretic,  anti- 
pyretic and  analgesic;   slightly  constipating. 

Toxic  Effect:    When  stomach  is  irritable  vomiting  may  result. 

Used  generally  in  single  dose  in  the  evening  for  malaise  or 
insomnia  in  acute  infections  such  as  "  grippe,"  tonsillitis,  or  the 
exanthemata. 

Dose:   fr.  10  to  15  grs.  (or  0.6  to  1  gm.)  in  pwd.  by  mouth. 

18.  Codeinae   sulphas.*      (U.S.)     "Codeine." 
Action:   mild  opiate  and  sedative.     Slightly  constipating. 
Toxic  Effect:   vomiting,  generally  on  following  day. 
Used  to  allay  unproductive  cough. 

Dose :    fr.  |  to  \  gr.  (or  0.008  to  0.032  gm.)  in  tablet,  by  mouth. 

19.  Sodii  bicarbonas.f    (U.  S.)    "  Soda."     "  Saleratus." 
Action:    antacid. 

Toxic  Effect:   gastric  disturbance,  not  poisonous. 

Used  for  "  hyperacidity,"  in  acidosis,  and  in  acid  poisoning; 
to  render  urine  alkaline;  and  with  salicylate  in  acute  rheumatism. 

Dose:  fr.  \  to  1  dr.  (or  2  to  4  gm.)  3  or  4  i.  d.  with  water  by 
mouth.     Larger  doses  may  be  required  in  acidosis. 

20.  Bismuthi  subnitras.    (U.  S.)    "  Bismuth." 
Action:    mild  astringent  and  antacid.     Combines  with  H2S  in 

intestine  to  form  a  black,  insoluble  sulphide. 

Toxic  Effect:   none  with  therapeutic  dose. 

Used  for  diarrhoea,  "  hyperacidity,"  peptic  ulcer,  and  for  in- 
testinal fermentation. 

Dose:  for  diarrhoea  fr.  10  to  20  grs.  (or  0.65  to  1.3  gm.)  re- 
peated after  each  loose  movement.  For  peptic  ulcer  t  doses 
of  1  dr.  (or  4  gm.)  are  used  a.  c.  to  coat  the  ulcer  and  to  relieve 
distress.     Prescribed  in  powd.  by  mouth  with  water. 

21.  Hydrargyri  chloridum  mite.     (U.  S.)    "Calomel." 
Action:     Mild  purgative  and  supposed  intestinal  antiseptic. 

Diuretic.     Antisyphilitic. 

*  Heroine  hydrochloride  may  be  preferred. 

t  Magnesii  oxidum  (U.  S.)  is  preferred  by  Dr.  R.  C.  Cabot. 

t  Use  a  pure  preparation:   e.  g.,  Squibb's. 


213 


Toxic  Effects:   renal  irritation,  stomatitis,  etc.  (p.  187). 

Use  and  Dose:  1.  as  a  mild  purge,  either  in  the  dose  of  tV  gr. 
(or  0.006  gm.)  every  15  m.  for  8  or  10  doses  and  followed  by  a 
mild  saline  cathartic  1  hour  after  the  last  dose,  or  fr.  1  to  3  grs. 
(or  0.065  to  0.2  gm.)  can  be  taken  in  single  dose  at  night  and  the 
saline  on  the  following  morning. 

2.  As  a  diuretic:  3  grs.  (or  0.2  gm.)  every  4  hours  for  fr.  24  to 
48  hours  or  until  diuresis  begins.  When  using  this  dose  the 
usual  precautions  against  poisoning  must  be  taken  (p,  187).  Pre- 
scribe in  tablet. 

3.  Calomel  is  preferred  by  many  to  salicylate  of  mercury  for 
the  treatment  of  syphilis  by  injection. 

22.  Oleum  ricini.     (U.S.)     "Castor  oil." 

Action:  mild  purgative;  acts  in  fr.  2  to  6  hours;  aftereffect 
constipating.  Do  not  prescribe  it  during  menstruation  or  preg- 
nancy. 

Toxic  Effect:  not  poisonous  but  may  be  vomited. 

Dose:  fr.  \  to  2  ozs.  or  more  (15  to  60  c.c).  Lemon  juice  or 
brandy  helps  to  disguise  the  taste. 

23.  Fluidextractum rhamni purshianae.  (U.S.)  "EI. 
ext.  of  cascara  sagrada." 

Action:   mild  laxative.     Taste:   very  bitter. 

Toxic  Effect:   irritation  of  bowel. 

Dose:  fr.  10  to  30  m.  (or  0.6  to  2  c.c.)  at  bed-time  with  water. 

24.  Vaccine  virus. 

The  living  virus  of  cow-pox  is  used  as  a  prophylactic  against 
small  pox.  The  virus  should  be  fresh,  and  a  "  take  "  or  lesion  of 
cow-pox  is  required  to  confer  immunity. 

Admin.  1.  Clean  skin  with  soap  and  water.  Antiseptics, 
if  used,  must  be  washed  off  lest  they  kill  the  virus. 

2.  When  dry,  scarify  skin  very  superficially  without  causing 
bleeding.     A  needle  or  any  sharp  instrument  will  serve. 

3.  Apply  virus.  After  it  has  dried  completely  cover  the  spot 
with  a  sterile  pad  and  secure  it  with  adhesive  plaster. 

4.  When  the  inoculation  "  has  taken "  the  lesion  should  be 
bathed  with  antiseptics  and  dressed  aseptically  from  time  to 
time.  Secondary  infection  and  much  pain  can  thus  be 
avoided. 

Note.  —  Virus  is  prepared  by  health  departments  nearly 
everywhere  and  is  distributed  free  to  physicians. 


215 

25.  Typhoid  vaccine. 

A  killed  culture  of  typhoid  bacilli  standardized  by  count. 
Used  for  prophylactic  inoculation  against  typhoid  (p.  65). 

In  general,  three  doses  are  given  subcut.  at  intervals  of  a 
week  or  ten  days  as  follows:  500  million,  1,000  million,  and  1,000 
million. 

The  reaction  is  seldom  severe.  There  may  be  fever  and  ma- 
laise. 

The  interval  between  injections  should  not  be  longer  than 
10  days  lest  anaphylaxis  result. 

Inoculation  is  strongly  recommended  for  persons  who  travel, 
for  nurses,  physicians,  soldiers  and  others  who  may  be  exposed 
to  typhoid  infection. 

Note.  —  Prepared  by  health  departments  *  and  pharmaceuti- 
cal firms. 

26.  Tuberculin. 

Used  for  diagnostic  tests  and  for  treatment  in  suitable  cases 
of  tuberculosis.  For  detailed  information  see  "  Early  Pulmonary 
Tuberculosis;  Diagnosis,  Prognosis,  and  Treatment,"  by  John 
B.  Hawes  2nd,  M.D.     (Wm.  Wood  &  Co.) 

There  are  several  kinds  of  tuberculin.  Koch's  old  tuberculin  is 
a  glycerine  extract  of  tubercle  bacilli.     It  is  still  used  extensively. 

27.  "  Normal  salt  solution." 

Used  by  hypodermoclysis,  intravenously,  or  by  rectum, 
depending  upon  circumstances  and  object  in  view. 

The  common  solution  consists  of  0.6  per  cent  of  sodium  chlo- 
ride in  distilled  water. 

Solutions  are  prepared  also  according  to  other  formulae  which 
contain  calcium  and  potassium  chloride  in  addition  to  sodium 
chloride. 

When  prescribing  specify  formula  desired. 

28.  Alcoholic  beverages. 

A.  (a)  Spiritus    frumenti.     (U.  S.)  "Whiskey." 

(6)  Spiritus  vini  Gallici.     (U.  S.)     "  Brandy." 
Uses: 
1.  Quickly  diffusible  stimulant:    dose  by  mouth,  fr.  1  drach. 

to  1  oz.   (or  4  to  30  c.c).      Dose  subcut.  30  min.   (or 

2  c.c). 


•  Distributed  free  in  Massachusetts  by  the  State  Board  of  Health. 


217 


2.  To    promote   appetite;    best  taken   with   meals   and   well 

diluted. 

3.  As   a  food  in  malnutrition  when  other  foods  are  not  ab- 

sorbed in  sufficient  quantity.  Alcohol  is  especially  useful 
in  selected  cases  of  typhoid  or  septic  infection. 

Dose  fr.  1  to  2  oz.  (or  30  to  60  c.c.)  diluted  with  water  and 
repeated  at  intervals  of  fr.  2  to  6  hours.  Larger  doses  are  some- 
times beneficial. 

If  odor  remains  on  breath  reduce  dose  or  lengthen  interval. 

Champagne  is  often  borne  better  than  whiskey  or  brandy 
when  the  stomach  is  irritable. 

B.  Beer,  ale,  porter,  or  malt  may  be  prescribed  with  meals 
to  improve  appetite  and  to  promote  increase  of  weight. 

29.   "  RUSSIAN  OIL" 

Petrolatum  liquidum  (U.  S.)  and  "  Russian  Oil "  are  liquid 
paraffins  under  the  definition  of  the  British  Pharmacopceia, 
but  "  Russian  Oil "  is  not  liquid  petrolatum  because  of  a  differ- 
ence between  Russian  and  American  Petroleum.  "  Russian 
Oil  "  is  more  refined  than  is  ordinarily  the  case  with  liquid  petro- 
latum. The  latter  usually  has  a  yellowish  color  and  an  unpleas- 
ant taste,  but  the  former  is  colorless  and  tasteless. 

Substitutes  for  "  Russian  Oil "  should  have  similar  general 
characteristics,  should  be  tasteless,  and  of  high  specific  gravity. 
Lighter  oils  seem  less  efficient,  and  sometimes  escape  through 
the  anus  involuntarily. 

Action:  A  lubricant  which  passes  unabsorbed  and  undigested 
through  the  intestine.  Unlike  olive  oil  it  is  not  a  food,  and  is 
less  apt  to  disturb  the  digestion. 

Used  chiefly  in  chronic  constipation,  alone  or  in  conjunction 
with  other  forms  of  treatment. 

Dose  from  1  to  3  tablespoonfuls  twice  daily;  preferably  several 
hours  after  a  meal. 

30.  AGAR-AGAR, 

Action:    Agar-agar  swells  tremendously  by  absorbing  water, 
is  not  digested,  and  does  not  ferment  in  the  intestinal  tract. 
Therefore,  it  stimulates  peristalsis  and  helps  to  sweep  out  the 
'  bowel. 


219 


Used  in  chronic  constipation,  generally  in  conjunction  with 
other  forms  of  treatment. 

Dose  from  |  to  1  tablespoonful  once  or  twice  daily. 

Administration:  Powdered  agar  can  be  eaten  on  cereal.  Gran- 
ulated agar  can  be  mixed  with  and  washed  down  with  milk  or 
water.     Agar-agar  wafers  are  more  attractive  but  expensive. 


221 

DRUGS  VALUABLE  FOR  OCCASIONAL  USE. 

i.  Thyroid  extract.* 

2.  Liquor    potassii    arsenitis.     (U.    S.)     "  Fowler's 

solution." 

3.  Pilocarpine  hydrochloridum.     (U.  S.) 

4.  Apomorphinae  hydrochloridum.     (U.  S.) 

5.  Vinum  colchici  seminis.     (U.  S.) 

6.  Quininae  hydrobromidum.     (U.  S.) 

7.  Hyoscinae  hydrobromidum  (U.  S.)        j  chemically 
Scopolamine  hydrobromidum  (U.  S.)  { the  same. 

8.  Caffeinae  sodio-salicylas.     (N.  F.) 

9.  Oleum  tiglii.     (U.  S.)     "  Croton  oil." 

10.  Elaterium.     (Br.) 

11.  Adrenalin  chloride  solution,!  1  to  1,000. 

12.  Cocainae  hydrochloridum.     (U.  S.) 

13.  Atropinae  sulphas.     (U.  S.) 

14.  Strophanthinum.     (U.  S.)t 

15.  Apocynum.     (U.  S.) 

16.  Theophylline^  p.  201. 

17.  Emetine  hydrochloride. § 


*  Not  official.     Burrough's,  Welcome  &  Co.'s  extract  is  good. 
t  U.  S.  t.     Parke,  Davis  &  Co. 
t  Boehringer'a  is  good. 
§  Not  official. 


223 

DRUGS   IN   COMMON   USE. 

i.  Ferrum  reductum.     (U.  S.) 

2.  Liquor     ferri     et     ammonii     acetatis.     (U.     S.) 

tl  Basham's  mixture." 

3.  Heroine  hydrochloride,*  p.  195. 

4.  Spiritus  ammoniae  aromaticus.     (U.  S.) 

5.  Potassii  bitartras.     (U.  S.)     "  Cream  of  tartar." 

6.  Potassii  citras.     (U.  S.) 

7.  Pilula  scillae  composita.     (Br.) 

8.  Liquor  antisepticus  alkalinus.     (N.  F.) 

"Alkaline  antiseptic." 

9.  Liquor  sodii  boratis  compositus.     (N.  F.)     "  Do- 

bell's  solution." 
Caffeina  citrata.     (U.  S.) 
Strychninae  sulphas.     (U.  S.) 
Tinctura  nucis  vomicae.     (U.  S.) 
Syrupus  hypophosphitum.     (U.  S.) 

"Syrup  of  hypophosphites." 
Syrupus    hypophosphitum    compositus.     (U.    S.) 

"  Compound  syrup  of  hypophosphites." 
Phillips'  Milk  of  Magnesia. f 
Senna.     (U.S.)     "  Senna  leaves." 
Glycerinum.     (U.  S.) 
Tinctura  iodi.     (U.  S.) 
Tinctura  belladonnas  foliorum.     (U.  S.) 

20.  Pilulae  catharticae  compositae.     (U.  S.) 

11  Compound  Cathartic  Pills." 

21.  Pilulae  aloini,  strychninae,  et  belladonnae. 

(N.  F.)     "A.  S.  andB.  Pills." 

*  Not  official.  t  Proprietary. 


225 

WEIGHTS   AND    MEASURES. 

METRIC   SYSTEM. 

1   kilogram    (kg.)  =  1    litre   of   distilled   water   at   maximum 
density,  i.e.,  at  4°  C.  and  760  mm.  pressure. 
1  kg.  =  1000  grams. 

1.0  gm.       =  gram.  (gm.). 
0.1  gm.       =  decigram  (dg.) 
0.01  gm.     =  centigram  (eg.). 
0.001  gm.  =  milligram  (nig.). 

APOTHECARIES'    OR  TROY  WEIGHT. 

1  grain  or  gr.  =  0.065  gm. 

1  drachm  (dr.  or  drach.)  or  5  =60  grs.  or  approx.  4  gm. 
1  ounce  (oz.)  or  o  =  8  dr.  =  480  grs.  or  approx.  30  gm. 
1  pound  (lb.)  =  12  o  or  approx.  375  gm. 

U.   S.   APOTHECARIES'    OR  WINE   MEASURE. 

1  minim  (min.)  or  m.  =  0.062  c.c.  (or  approx.  1  drop  of  water). 
1  fl.  drachm  (drach.  or  dr.)  or  5  =  60  m.  or  approx.  4  c.c. 
1  fl.  ounce  *  (oz.)  or  o  =  8  dr.  =  480  m.  or  approx.  30  c.c. 
1  pint  (O)  =  16  §  or  approx.  480  c.c. 


*  1  fl.  oz.  of  water  weighs  455.6  grs. 


A  Companion  Volume  to 
Shattuck's  Principles  of  Medical  Treatment 


A  MANUAL  OF 

Practical  Laboratory  Diagnosis 

By  LEWIS  WEBB  HILL,  M.D. 


"  It  has  seemed  to  the  Author  for  a  long  time  that 
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the  Schick  test,  the  von  Pirquet  test,  Tables  of  Gram 
positive  and  Gram  negative  organisms,  and  of  Diseases' 
in  which  Leucocytosis  is  present  or  absent. 

Eleven  Figures  and  Eight  Plates,  Four  of  which 
are  colored,  illustrate  the  Text.  To  provide  for  notes, 
the  text  is  printed  upon  alternate  pages. 


"  There  must  be  many  physicians  who 
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THE  MEDICAL  BOOK  OF  THE  YEAR 

The  Allen  (Starvation) 
Treatment   of   Diabetes 

SECOND  EDITION,   THIRD   PRINTING 

By  LEWIS  W.  HILL,  M.D. 

and 

RENA  S.  ECKMAN 

Dietitian  at  the  Massachusetts  General  Hospital 


This  Book 

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Typical  Case  Histories  of  Adults  and  Children. 
Complete  Daily  Diet  Lists,  with  Protein,  Carbo- 
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Typical   Diet  List   for  First    Fifteen    Days  after 

Starvation. 
Recipes  for  Comfort  as  well  as  Safety  of  Diabetics. 
Table  of  Food  Values. 


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Price  Postpaid     :     :     :     :     ONE    DOLLAR 

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